| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
380 |
378 |
$10K |
| D1110 |
Prophylaxis - adult |
123 |
121 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
139 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
786 |
318 |
$5K |
| D1120 |
Prophylaxis - child |
122 |
120 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
384 |
368 |
$4K |
| D0274 |
Bitewings - four radiographic images |
190 |
190 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
122 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$966.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$540.00 |