| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
309 |
304 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
176 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
214 |
154 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
177 |
177 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
40 |
$2K |
| D4355 |
|
24 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
58 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
383 |
376 |
$343.69 |
| D0274 |
Bitewings - four radiographic images |
339 |
336 |
$99.05 |
| D0330 |
Panoramic radiographic image |
112 |
109 |
$64.36 |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
445 |
$20.00 |
| D1330 |
|
12 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |