| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,024 |
2,980 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
2,914 |
2,870 |
$46K |
| D0210 |
Intraoral - complete series of radiographic images |
1,108 |
1,107 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,306 |
2,056 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,962 |
2,850 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
587 |
578 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
602 |
601 |
$9K |
| D0274 |
Bitewings - four radiographic images |
428 |
423 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
251 |
251 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
15 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
16 |
$1K |
| D1120 |
Prophylaxis - child |
60 |
60 |
$1K |
| D2954 |
|
15 |
14 |
$692.25 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$35.00 |