| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
183 |
183 |
$10K |
| D1110 |
Prophylaxis - adult |
242 |
242 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
61 |
61 |
$4K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
39 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
41 |
$843.69 |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$182.59 |
| D0120 |
Periodic oral evaluation - established patient |
301 |
301 |
$109.58 |
| D0220 |
Intraoral - periapical first radiographic image |
314 |
313 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
313 |
236 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
239 |
239 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$0.00 |