| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
971 |
969 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
780 |
608 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
1,183 |
1,147 |
$2K |
| D0274 |
Bitewings - four radiographic images |
390 |
388 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
965 |
961 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
140 |
127 |
$950.00 |
| D0330 |
Panoramic radiographic image |
372 |
372 |
$249.00 |
| D1999 |
|
915 |
804 |
$0.00 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
212 |
211 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
24 |
$0.00 |