| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
645 |
640 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
978 |
969 |
$55K |
| D1120 |
Prophylaxis - child |
1,203 |
1,196 |
$46K |
| D9430 |
|
1,288 |
1,249 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,071 |
1,948 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,066 |
2,052 |
$26K |
| D0350 |
|
1,550 |
785 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
426 |
421 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,489 |
1,482 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
198 |
104 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
209 |
208 |
$13K |
| D1351 |
Sealant - per tooth |
227 |
58 |
$7K |
| D4341 |
|
88 |
24 |
$6K |
| D1206 |
Topical application of fluoride varnish |
255 |
255 |
$4K |
| D4910 |
|
26 |
26 |
$2K |
| D2160 |
|
20 |
12 |
$2K |
| D2140 |
|
26 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
86 |
$988.00 |