| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1999 |
|
200 |
164 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
165 |
163 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
39 |
$2K |
| D0274 |
Bitewings - four radiographic images |
115 |
113 |
$2K |
| D1330 |
|
35 |
35 |
$2K |
| D1110 |
Prophylaxis - adult |
155 |
153 |
$839.03 |
| D0140 |
Limited oral evaluation - problem focused |
32 |
32 |
$479.02 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
17 |
$375.42 |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
62 |
$163.00 |
| D0220 |
Intraoral - periapical first radiographic image |
169 |
166 |
$68.11 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
113 |
112 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
165 |
159 |
$0.00 |
| D3120 |
|
32 |
13 |
$0.00 |