| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
254 |
241 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
127 |
119 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
281 |
273 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
135 |
$3K |
| D1120 |
Prophylaxis - child |
68 |
68 |
$3K |
| D1206 |
Topical application of fluoride varnish |
99 |
99 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
147 |
$998.10 |
| D0274 |
Bitewings - four radiographic images |
58 |
55 |
$990.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
14 |
$101.00 |