| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
549 |
530 |
$16K |
| D9630 |
|
983 |
953 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
475 |
454 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
564 |
543 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
119 |
108 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
187 |
173 |
$5K |
| D1120 |
Prophylaxis - child |
36 |
25 |
$824.64 |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$430.56 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
42 |
$377.78 |
| D2950 |
|
38 |
13 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
30 |
12 |
$0.00 |