| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,741 |
1,739 |
$71K |
| D0274 |
Bitewings - four radiographic images |
1,303 |
1,303 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,212 |
1,212 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,264 |
2,246 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
551 |
550 |
$12K |
| D0330 |
Panoramic radiographic image |
356 |
355 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,629 |
1,621 |
$8K |
| D0350 |
|
1,036 |
1,032 |
$7K |
| D1320 |
|
474 |
474 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
210 |
207 |
$2K |
| D1120 |
Prophylaxis - child |
55 |
55 |
$2K |
| D9110 |
|
171 |
169 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
80 |
80 |
$880.00 |
| D0140 |
Limited oral evaluation - problem focused |
32 |
32 |
$260.88 |
| D0470 |
|
14 |
14 |
$249.71 |