| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,863 |
2,863 |
$98K |
| D0274 |
Bitewings - four radiographic images |
1,576 |
1,576 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,380 |
1,380 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,381 |
1,380 |
$27K |
| D0330 |
Panoramic radiographic image |
1,069 |
1,069 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,200 |
2,173 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
1,254 |
1,233 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,634 |
1,633 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
637 |
633 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
64 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
82 |
$4K |
| D0270 |
|
27 |
27 |
$265.43 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$69.50 |