| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
400 |
398 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
463 |
462 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
80 |
$13K |
| D0274 |
Bitewings - four radiographic images |
327 |
327 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
42 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
160 |
158 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
164 |
164 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
355 |
352 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
252 |
204 |
$2K |
| D1206 |
Topical application of fluoride varnish |
80 |
80 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$810.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$630.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$407.00 |
| D9110 |
|
12 |
12 |
$360.00 |
| D0270 |
|
13 |
13 |
$152.00 |