| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
149 |
149 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
108 |
108 |
$3K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$3K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
26 |
$3K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
16 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
106 |
$2K |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$936.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
51 |
$533.50 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$262.50 |