| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,398 |
1,339 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
1,122 |
1,069 |
$25K |
| D0274 |
Bitewings - four radiographic images |
410 |
395 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
72 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
75 |
$2K |
| D0330 |
Panoramic radiographic image |
39 |
37 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
24 |
$2K |
| D1206 |
Topical application of fluoride varnish |
28 |
26 |
$700.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$200.00 |
| D1999 |
|
14 |
12 |
$0.00 |