| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
375 |
358 |
$5K |
| D0274 |
Bitewings - four radiographic images |
519 |
498 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
222 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,200 |
371 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
606 |
558 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
219 |
209 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
24 |
$1K |
| D0330 |
Panoramic radiographic image |
84 |
78 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
44 |
$496.76 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
12 |
$409.68 |
| D1206 |
Topical application of fluoride varnish |
25 |
24 |
$225.00 |
| D1999 |
|
331 |
261 |
$0.00 |
| D9986 |
|
12 |
12 |
$0.00 |