| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,609 |
3,603 |
$159K |
| D0120 |
Periodic oral evaluation - established patient |
4,420 |
4,415 |
$99K |
| D2750 |
|
114 |
93 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
3,537 |
3,515 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,025 |
3,021 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,156 |
1,156 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
175 |
174 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
204 |
204 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
13 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
39 |
$430.60 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$394.70 |
| D1320 |
|
12 |
12 |
$88.00 |
| D1310 |
|
12 |
12 |
$0.00 |
| D1330 |
|
12 |
12 |
$0.00 |