| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,864 |
1,861 |
$69K |
| D0274 |
Bitewings - four radiographic images |
1,657 |
1,656 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,694 |
2,568 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,159 |
1,156 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,480 |
2,424 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
499 |
499 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
168 |
153 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
37 |
$390.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$289.40 |
| D1999 |
|
41 |
35 |
$0.00 |