| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
628 |
560 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
313 |
255 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
394 |
357 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
396 |
343 |
$9K |
| D0274 |
Bitewings - four radiographic images |
125 |
119 |
$5K |
| D1206 |
Topical application of fluoride varnish |
216 |
189 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
25 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
75 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
198 |
169 |
$2K |
| D1120 |
Prophylaxis - child |
26 |
25 |
$793.50 |
| D0330 |
Panoramic radiographic image |
14 |
12 |
$650.39 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
25 |
$276.00 |