| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,597 |
1,589 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,442 |
1,434 |
$28K |
| D0274 |
Bitewings - four radiographic images |
826 |
823 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,132 |
1,121 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,163 |
1,151 |
$8K |
| D0330 |
Panoramic radiographic image |
242 |
240 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
137 |
137 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
16 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
38 |
$946.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$524.00 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$289.93 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$207.20 |