| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
380 |
380 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
203 |
148 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
74 |
74 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
215 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
99 |
59 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
173 |
172 |
$4K |
| D2331 |
|
50 |
28 |
$3K |
| D4341 |
|
33 |
15 |
$3K |
| D4910 |
|
28 |
28 |
$2K |
| D1354 |
|
790 |
91 |
$2K |
| D0274 |
Bitewings - four radiographic images |
359 |
359 |
$2K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$931.87 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$714.39 |
| D0220 |
Intraoral - periapical first radiographic image |
441 |
433 |
$44.40 |
| D0120 |
Periodic oral evaluation - established patient |
299 |
299 |
$32.22 |
| D1206 |
Topical application of fluoride varnish |
124 |
124 |
$14.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
504 |
287 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
82 |
82 |
$0.00 |