| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
329 |
309 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
322 |
290 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
27 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$2K |
| D0274 |
Bitewings - four radiographic images |
266 |
239 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
390 |
350 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
26 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
289 |
260 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$585.00 |
| D1330 |
|
119 |
119 |
$0.00 |