| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,391 |
1,391 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
632 |
625 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
772 |
772 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
728 |
728 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
601 |
593 |
$6K |
| D0274 |
Bitewings - four radiographic images |
208 |
208 |
$4K |
| D9944 |
|
42 |
42 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
25 |
$3K |
| D9110 |
|
123 |
123 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
226 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
167 |
161 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$168.00 |