| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,397 |
1,396 |
$70K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
735 |
327 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,305 |
1,304 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,811 |
1,810 |
$35K |
| D2140 |
|
628 |
276 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,050 |
1,050 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,187 |
1,186 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,606 |
1,598 |
$30K |
| D2332 |
|
284 |
131 |
$29K |
| D2335 |
|
107 |
57 |
$15K |
| D0272 |
Bitewings - two radiographic images |
858 |
858 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
968 |
960 |
$9K |
| D2160 |
|
21 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
90 |
$1K |
| D2330 |
|
21 |
12 |
$1K |
| D1320 |
|
134 |
134 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$140.00 |