| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
378 |
368 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
476 |
463 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
132 |
131 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
106 |
65 |
$3K |
| D3310 |
|
20 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
177 |
171 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
118 |
118 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
265 |
181 |
$916.00 |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
173 |
$894.60 |
| D1120 |
Prophylaxis - child |
36 |
36 |
$567.00 |
| D1999 |
|
107 |
86 |
$380.59 |
| D0120 |
Periodic oral evaluation - established patient |
36 |
35 |
$356.40 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$269.10 |