| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,449 |
2,449 |
$141K |
| D1110 |
Prophylaxis - adult |
1,276 |
1,273 |
$108K |
| D1120 |
Prophylaxis - child |
1,695 |
1,694 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,875 |
2,637 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,335 |
3,332 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
675 |
675 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
828 |
827 |
$39K |
| D4910 |
|
410 |
410 |
$31K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
412 |
188 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,223 |
1,222 |
$26K |
| D0330 |
Panoramic radiographic image |
756 |
755 |
$22K |
| D9430 |
|
410 |
404 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
939 |
890 |
$11K |
| D0350 |
|
723 |
330 |
$7K |
| D1351 |
Sealant - per tooth |
272 |
85 |
$6K |
| D4341 |
|
45 |
14 |
$3K |
| D2140 |
|
39 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
60 |
60 |
$708.00 |