| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,077 |
1,074 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
604 |
603 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
839 |
837 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
372 |
372 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
381 |
375 |
$4K |
| D0274 |
Bitewings - four radiographic images |
72 |
72 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
19 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
115 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
68 |
$816.34 |
| D1120 |
Prophylaxis - child |
19 |
19 |
$465.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$323.60 |
| D1999 |
|
37 |
35 |
$0.00 |
| D1330 |
|
44 |
44 |
$0.00 |