| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,793 |
2,792 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,234 |
3,234 |
$66K |
| D2750 |
|
108 |
92 |
$52K |
| D0274 |
Bitewings - four radiographic images |
2,452 |
2,452 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
4,031 |
4,018 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,604 |
3,604 |
$31K |
| D1120 |
Prophylaxis - child |
998 |
998 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
690 |
690 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,279 |
1,279 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
265 |
264 |
$5K |
| D9110 |
|
235 |
235 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
62 |
56 |
$4K |
| D0272 |
Bitewings - two radiographic images |
252 |
252 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$765.92 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$269.00 |
| D1999 |
|
67 |
66 |
$0.00 |