| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
218 |
201 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
261 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
50 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
102 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
80 |
$2K |
| D0274 |
Bitewings - four radiographic images |
88 |
88 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
215 |
199 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
164 |
117 |
$2K |
| D1120 |
Prophylaxis - child |
77 |
76 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
80 |
79 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
48 |
$912.30 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$279.76 |
| D1330 |
|
42 |
38 |
$190.00 |
| D9986 |
|
60 |
56 |
$0.00 |