| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
999 |
998 |
$17K |
| D1110 |
Prophylaxis - adult |
515 |
515 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
784 |
781 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
482 |
481 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
135 |
135 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
63 |
$673.00 |
| D0272 |
Bitewings - two radiographic images |
65 |
65 |
$225.00 |