| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,026 |
4,024 |
$139K |
| D0120 |
Periodic oral evaluation - established patient |
4,115 |
4,115 |
$75K |
| D0210 |
Intraoral - complete series of radiographic images |
1,931 |
1,929 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,630 |
2,630 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,100 |
2,100 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
4,555 |
4,550 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,655 |
3,646 |
$37K |
| D1120 |
Prophylaxis - child |
696 |
696 |
$20K |
| D0272 |
Bitewings - two radiographic images |
837 |
837 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,021 |
1,021 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
17 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
165 |
165 |
$442.13 |
| D1351 |
Sealant - per tooth |
21 |
14 |
$290.44 |
| D1999 |
|
358 |
347 |
$0.00 |