| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,234 |
1,233 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,449 |
1,449 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
418 |
261 |
$30K |
| D0274 |
Bitewings - four radiographic images |
549 |
549 |
$15K |
| D1120 |
Prophylaxis - child |
333 |
332 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
328 |
328 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
654 |
653 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
59 |
$5K |
| D0330 |
Panoramic radiographic image |
123 |
123 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
74 |
74 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
251 |
250 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$481.30 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$477.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
42 |
$342.40 |
| D1999 |
|
80 |
73 |
$0.00 |