| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
234 |
233 |
$7K |
| D1110 |
Prophylaxis - adult |
154 |
154 |
$6K |
| D1120 |
Prophylaxis - child |
123 |
123 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
26 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
71 |
71 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$2K |
| D0274 |
Bitewings - four radiographic images |
136 |
136 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
315 |
312 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
239 |
238 |
$720.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$585.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$168.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$120.00 |
| D1330 |
|
205 |
205 |
$0.00 |