| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
888 |
888 |
$26K |
| D1120 |
Prophylaxis - child |
720 |
720 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
938 |
938 |
$8K |
| D0272 |
Bitewings - two radiographic images |
317 |
317 |
$6K |
| D1110 |
Prophylaxis - adult |
143 |
143 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
345 |
344 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
74 |
42 |
$3K |
| D0274 |
Bitewings - four radiographic images |
88 |
88 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
174 |
172 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$698.88 |