| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
266 |
266 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
225 |
225 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
28 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
139 |
131 |
$7K |
| D1206 |
Topical application of fluoride varnish |
245 |
245 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
13 |
$6K |
| D0274 |
Bitewings - four radiographic images |
180 |
180 |
$4K |
| D0330 |
Panoramic radiographic image |
69 |
69 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
94 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
187 |
167 |
$2K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
14 |
$150.88 |
| D1330 |
|
15 |
15 |
$108.00 |