| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
179 |
152 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
154 |
129 |
$3K |
| D0274 |
Bitewings - four radiographic images |
200 |
170 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
331 |
280 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
95 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
372 |
219 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
57 |
37 |
$321.00 |
| D1999 |
|
146 |
112 |
$0.00 |