| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,103 |
1,059 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,056 |
1,007 |
$22K |
| D0274 |
Bitewings - four radiographic images |
225 |
214 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
37 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
58 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
25 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
29 |
$688.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
14 |
$581.00 |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
42 |
$562.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$403.00 |