| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
87 |
87 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
181 |
178 |
$1K |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$631.49 |
| D0120 |
Periodic oral evaluation - established patient |
33 |
33 |
$447.01 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$333.50 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$234.86 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$169.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$63.23 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$48.63 |
| D1330 |
|
32 |
32 |
$0.00 |