| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,104 |
1,098 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,057 |
1,049 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
236 |
236 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,341 |
1,311 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
41 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,352 |
823 |
$3K |
| D0274 |
Bitewings - four radiographic images |
458 |
455 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
856 |
851 |
$2K |
| D0330 |
Panoramic radiographic image |
614 |
607 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
120 |
118 |
$1K |
| D1120 |
Prophylaxis - child |
95 |
92 |
$859.00 |
| D1206 |
Topical application of fluoride varnish |
87 |
83 |
$412.50 |
| D0272 |
Bitewings - two radiographic images |
29 |
28 |
$48.00 |
| D1999 |
|
777 |
735 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$0.00 |