| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,654 |
1,651 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,233 |
1,230 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
331 |
330 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
205 |
118 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
539 |
539 |
$8K |
| D0274 |
Bitewings - four radiographic images |
761 |
761 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,251 |
1,237 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
286 |
286 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
114 |
114 |
$1K |
| D2140 |
|
18 |
12 |
$777.50 |
| D0272 |
Bitewings - two radiographic images |
98 |
98 |
$475.02 |
| D1999 |
|
844 |
748 |
$0.00 |