| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
743 |
739 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
346 |
345 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
557 |
553 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
957 |
932 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
411 |
409 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
160 |
159 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
16 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$4K |
| D0274 |
Bitewings - four radiographic images |
128 |
127 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D1206 |
Topical application of fluoride varnish |
53 |
51 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$399.60 |