| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,277 |
3,274 |
$156K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,513 |
767 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
4,622 |
4,619 |
$125K |
| D2160 |
|
698 |
362 |
$73K |
| D1120 |
Prophylaxis - child |
1,845 |
1,838 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,010 |
3,007 |
$59K |
| D0272 |
Bitewings - two radiographic images |
2,448 |
2,441 |
$52K |
| D2140 |
|
335 |
238 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
339 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
251 |
251 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,001 |
985 |
$14K |
| D1351 |
Sealant - per tooth |
464 |
230 |
$13K |
| D2161 |
|
39 |
25 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
294 |
255 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$765.00 |