| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
300 |
300 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
110 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
12 |
$7K |
| D1120 |
Prophylaxis - child |
70 |
70 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
57 |
$2K |
| D9420 |
|
34 |
34 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
24 |
$1K |
| D9310 |
|
57 |
56 |
$852.88 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$567.86 |
| D2950 |
|
28 |
24 |
$383.67 |
| D0274 |
Bitewings - four radiographic images |
278 |
278 |
$224.44 |
| D0120 |
Periodic oral evaluation - established patient |
396 |
396 |
$97.36 |
| D0220 |
Intraoral - periapical first radiographic image |
379 |
371 |
$59.45 |
| D0270 |
|
69 |
64 |
$8.93 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
433 |
433 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
335 |
179 |
$0.00 |