| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,495 |
2,481 |
$91K |
| D1206 |
Topical application of fluoride varnish |
4,008 |
3,978 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
3,390 |
3,365 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,842 |
1,923 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,398 |
1,385 |
$34K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
528 |
352 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,250 |
2,210 |
$25K |
| D1120 |
Prophylaxis - child |
732 |
728 |
$22K |
| D0603 |
|
615 |
612 |
$3K |
| D0330 |
Panoramic radiographic image |
50 |
49 |
$2K |
| D0272 |
Bitewings - two radiographic images |
98 |
97 |
$2K |
| D2160 |
|
16 |
12 |
$1K |
| D2140 |
|
17 |
14 |
$814.84 |
| D4910 |
|
12 |
12 |
$736.92 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$309.65 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$298.56 |
| D0601 |
|
27 |
27 |
$130.00 |