| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
180 |
180 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
235 |
235 |
$5K |
| D1110 |
Prophylaxis - adult |
96 |
96 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
264 |
263 |
$2K |
| D0274 |
Bitewings - four radiographic images |
86 |
86 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
72 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
83 |
83 |
$1K |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$500.65 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$469.85 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$278.71 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$95.64 |
| D1330 |
|
189 |
189 |
$0.00 |