| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,423 |
1,419 |
$120K |
| D0120 |
Periodic oral evaluation - established patient |
1,783 |
1,778 |
$101K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,021 |
1,019 |
$64K |
| D1120 |
Prophylaxis - child |
1,362 |
1,354 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,943 |
2,927 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,157 |
2,439 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,296 |
1,294 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
515 |
514 |
$24K |
| D9430 |
|
566 |
524 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
201 |
89 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
268 |
267 |
$3K |
| D2140 |
|
44 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$633.00 |
| D1999 |
|
223 |
199 |
$0.00 |