| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,577 |
1,577 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,854 |
1,846 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,218 |
1,218 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,726 |
2,672 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
1,008 |
989 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
352 |
352 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
49 |
$4K |
| D0272 |
Bitewings - two radiographic images |
161 |
161 |
$2K |
| D2954 |
|
12 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$414.20 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$393.51 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$128.18 |