| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
230 |
209 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
184 |
166 |
$3K |
| D0274 |
Bitewings - four radiographic images |
185 |
168 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
148 |
133 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$908.00 |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
148 |
$831.90 |
| D0272 |
Bitewings - two radiographic images |
112 |
96 |
$551.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
167 |
149 |
$519.60 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$342.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$284.00 |
| D1999 |
|
137 |
114 |
$0.00 |