| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
797 |
797 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
553 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
306 |
305 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
440 |
440 |
$12K |
| D0274 |
Bitewings - four radiographic images |
270 |
270 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
584 |
582 |
$8K |
| D0330 |
Panoramic radiographic image |
180 |
180 |
$7K |
| D2332 |
|
36 |
12 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
199 |
198 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
52 |
$730.00 |