| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,750 |
1,750 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
2,374 |
2,374 |
$71K |
| D1120 |
Prophylaxis - child |
1,359 |
1,359 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,313 |
1,313 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
536 |
536 |
$16K |
| D0274 |
Bitewings - four radiographic images |
358 |
358 |
$13K |
| D0272 |
Bitewings - two radiographic images |
290 |
290 |
$6K |
| D1206 |
Topical application of fluoride varnish |
108 |
108 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
32 |
24 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
26 |
25 |
$164.23 |
| D1999 |
|
60 |
56 |
$0.00 |