| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,510 |
2,508 |
$114K |
| D1120 |
Prophylaxis - child |
2,603 |
2,603 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
4,081 |
4,081 |
$79K |
| D0274 |
Bitewings - four radiographic images |
2,302 |
2,302 |
$65K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
656 |
512 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,185 |
1,185 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,324 |
2,324 |
$30K |
| D2140 |
|
615 |
452 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
1,042 |
1,035 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,089 |
1,089 |
$18K |
| D0330 |
Panoramic radiographic image |
372 |
372 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,209 |
1,194 |
$13K |
| D0272 |
Bitewings - two radiographic images |
512 |
512 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
86 |
$4K |
| D2160 |
|
27 |
25 |
$2K |
| D1351 |
Sealant - per tooth |
36 |
13 |
$900.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
175 |
$668.90 |
| D1999 |
|
16 |
15 |
$0.00 |