| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 11721 |
|
14,740 |
14,717 |
$90K |
| D9920 |
|
1,941 |
1,928 |
$89K |
| D1110 |
Prophylaxis - adult |
1,507 |
1,498 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
908 |
901 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,381 |
1,376 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
424 |
419 |
$22K |
| 92557 |
|
736 |
729 |
$12K |
| 11056 |
|
835 |
832 |
$9K |
| 11720 |
|
629 |
628 |
$4K |
| D9410 |
|
112 |
111 |
$3K |
| 99305 |
|
117 |
116 |
$2K |
| D0274 |
Bitewings - four radiographic images |
75 |
75 |
$2K |
| 11055 |
|
191 |
189 |
$2K |
| 92015 |
Determination of refractive state |
138 |
137 |
$2K |
| 92551 |
|
100 |
100 |
$938.51 |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
66 |
65 |
$814.03 |
| 99304 |
|
188 |
187 |
$761.93 |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
105 |
$580.00 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$462.00 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$364.00 |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
68 |
68 |
$271.33 |
| 11057 |
|
12 |
12 |
$0.70 |
| 99307 |
|
46 |
46 |
$0.00 |
| D1330 |
|
76 |
75 |
$0.00 |