| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
779 |
766 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
765 |
751 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
90 |
$12K |
| D0274 |
Bitewings - four radiographic images |
177 |
177 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
568 |
490 |
$6K |
| D1206 |
Topical application of fluoride varnish |
311 |
307 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
326 |
284 |
$3K |
| D0330 |
Panoramic radiographic image |
40 |
39 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
44 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$533.92 |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
15 |
$292.16 |
| D1999 |
|
31 |
30 |
$0.00 |