| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
203 |
172 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
216 |
189 |
$3K |
| D0274 |
Bitewings - four radiographic images |
183 |
157 |
$2K |
| D0330 |
Panoramic radiographic image |
69 |
49 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
813 |
203 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
64 |
$878.66 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$832.00 |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
189 |
$661.39 |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
45 |
$525.68 |
| D1120 |
Prophylaxis - child |
22 |
22 |
$409.44 |
| D0999 |
Unspecified diagnostic procedure, by report |
65 |
64 |
$0.00 |