| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
95 |
94 |
$4K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
62 |
62 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$585.00 |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$456.00 |
| D0220 |
Intraoral - periapical first radiographic image |
191 |
168 |
$440.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
152 |
124 |
$366.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$350.00 |
| D1330 |
|
73 |
62 |
$0.00 |