| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
878 |
877 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,069 |
1,069 |
$68K |
| D1206 |
Topical application of fluoride varnish |
1,432 |
1,425 |
$22K |
| D9920 |
|
191 |
188 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
443 |
442 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
230 |
$15K |
| D0274 |
Bitewings - four radiographic images |
708 |
708 |
$14K |
| D4910 |
|
127 |
127 |
$9K |
| D1120 |
Prophylaxis - child |
222 |
222 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,737 |
914 |
$7K |
| D9430 |
|
142 |
141 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
16 |
12 |
$1K |
| D9410 |
|
35 |
35 |
$953.00 |