| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,439 |
1,438 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,489 |
1,487 |
$35K |
| D0274 |
Bitewings - four radiographic images |
836 |
836 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
256 |
256 |
$10K |
| D0330 |
Panoramic radiographic image |
164 |
164 |
$9K |
| D1206 |
Topical application of fluoride varnish |
324 |
323 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
29 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
114 |
113 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
259 |
255 |
$3K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
103 |
103 |
$593.37 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$150.09 |