| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
333 |
331 |
$10K |
| D0330 |
Panoramic radiographic image |
145 |
144 |
$10K |
| D1120 |
Prophylaxis - child |
275 |
274 |
$9K |
| D1110 |
Prophylaxis - adult |
162 |
162 |
$8K |
| D1206 |
Topical application of fluoride varnish |
289 |
287 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
28 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
78 |
78 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
85 |
85 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$782.21 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$0.00 |