| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
931 |
930 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,152 |
1,152 |
$21K |
| D0274 |
Bitewings - four radiographic images |
730 |
730 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
306 |
306 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,302 |
1,291 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
870 |
867 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
123 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
125 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$889.75 |
| D1120 |
Prophylaxis - child |
37 |
37 |
$865.51 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$198.46 |