| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,080 |
1,077 |
$80K |
| D1120 |
Prophylaxis - child |
800 |
799 |
$44K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
305 |
169 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
260 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
216 |
215 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$972.98 |
| D0274 |
Bitewings - four radiographic images |
595 |
592 |
$813.77 |
| D0120 |
Periodic oral evaluation - established patient |
1,720 |
1,717 |
$698.89 |
| D1351 |
Sealant - per tooth |
59 |
12 |
$249.96 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,401 |
1,400 |
$83.88 |
| D0220 |
Intraoral - periapical first radiographic image |
722 |
713 |
$62.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
704 |
285 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
224 |
223 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
510 |
492 |
$0.00 |
| D1999 |
|
788 |
777 |
$-236.44 |