| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,145 |
1,145 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,119 |
1,118 |
$22K |
| D0274 |
Bitewings - four radiographic images |
923 |
923 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,447 |
1,427 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,178 |
1,175 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
212 |
212 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
79 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
66 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
83 |
83 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
97 |
$949.15 |
| D0180 |
|
13 |
13 |
$0.00 |