| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
727 |
727 |
$9K |
| D1110 |
Prophylaxis - adult |
636 |
636 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
753 |
752 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
127 |
127 |
$2K |
| D0274 |
Bitewings - four radiographic images |
274 |
274 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
171 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
431 |
431 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$406.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$148.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
88 |
88 |
$102.00 |
| D0272 |
Bitewings - two radiographic images |
65 |
65 |
$75.00 |