| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,809 |
1,802 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,236 |
1,224 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,441 |
1,907 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
917 |
914 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,031 |
1,024 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
385 |
384 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
2,392 |
2,314 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
249 |
239 |
$3K |
| D0272 |
Bitewings - two radiographic images |
601 |
594 |
$3K |
| D1120 |
Prophylaxis - child |
73 |
67 |
$980.75 |
| D1206 |
Topical application of fluoride varnish |
57 |
54 |
$785.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
14 |
$606.00 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$261.00 |
| D9211 |
|
51 |
37 |
$0.00 |