| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,375 |
1,374 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
1,323 |
1,305 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
306 |
302 |
$10K |
| D0274 |
Bitewings - four radiographic images |
477 |
477 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
469 |
468 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
354 |
354 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
883 |
882 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
26 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$625.28 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$257.38 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$132.30 |
| D0350 |
|
12 |
12 |
$118.32 |
| D1999 |
|
206 |
178 |
$0.00 |
| D1330 |
|
273 |
272 |
$0.00 |