| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
938 |
937 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
622 |
611 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
756 |
756 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
888 |
861 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
412 |
411 |
$9K |
| D9310 |
|
107 |
107 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
499 |
490 |
$4K |
| D0274 |
Bitewings - four radiographic images |
147 |
146 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
130 |
130 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
59 |
$639.33 |
| D1320 |
|
12 |
12 |
$96.00 |
| D1999 |
|
34 |
31 |
$0.00 |
| D0180 |
|
12 |
12 |
$0.00 |