| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,569 |
2,568 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
2,584 |
2,584 |
$51K |
| D0330 |
Panoramic radiographic image |
903 |
903 |
$21K |
| D0274 |
Bitewings - four radiographic images |
741 |
741 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
1,423 |
1,406 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,405 |
1,397 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
521 |
521 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
771 |
770 |
$10K |
| D1120 |
Prophylaxis - child |
323 |
323 |
$9K |
| D0270 |
|
377 |
376 |
$4K |
| D1206 |
Topical application of fluoride varnish |
53 |
53 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$530.28 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$305.20 |
| D1330 |
|
1,522 |
1,506 |
$0.00 |
| D0603 |
|
71 |
71 |
$0.00 |
| D4355 |
|
297 |
297 |
$0.00 |
| D0602 |
|
764 |
763 |
$0.00 |
| D9630 |
|
143 |
143 |
$0.00 |
| D0601 |
|
22 |
22 |
$0.00 |