| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
822 |
820 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
533 |
531 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
102 |
63 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
523 |
515 |
$3K |
| D0274 |
Bitewings - four radiographic images |
195 |
195 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
286 |
284 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
19 |
19 |
$855.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$540.00 |
| D1999 |
|
300 |
273 |
$0.00 |