| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,787 |
1,783 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,836 |
1,832 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,217 |
1,162 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
416 |
416 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,678 |
1,646 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
129 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
55 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
82 |
82 |
$648.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
63 |
$338.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$117.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$45.00 |