| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
210 |
205 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
352 |
346 |
$9K |
| D0274 |
Bitewings - four radiographic images |
269 |
265 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
62 |
$2K |
| D2940 |
|
28 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
12 |
$683.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
428 |
418 |
$625.79 |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$507.36 |
| D1330 |
|
428 |
422 |
$278.91 |
| D0220 |
Intraoral - periapical first radiographic image |
451 |
437 |
$160.00 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$90.83 |
| D1208 |
Topical application of fluoride, excluding varnish |
357 |
351 |
$16.35 |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$0.00 |