| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,052 |
1,048 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,047 |
1,045 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
539 |
531 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,091 |
1,084 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
944 |
940 |
$8K |
| D0274 |
Bitewings - four radiographic images |
261 |
260 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
158 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
225 |
221 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
25 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
72 |
$775.80 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$393.51 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$314.75 |