| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2394 |
|
492 |
237 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
1,257 |
1,245 |
$4K |
| D0274 |
Bitewings - four radiographic images |
768 |
751 |
$3K |
| D1110 |
Prophylaxis - adult |
565 |
551 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,447 |
1,424 |
$3K |
| D1120 |
Prophylaxis - child |
367 |
363 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
660 |
642 |
$693.14 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
75 |
50 |
$432.00 |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$177.82 |
| D0230 |
Intraoral - periapical each additional radiographic image |
233 |
214 |
$172.02 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$25.00 |
| D1999 |
|
19 |
19 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$0.00 |