| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
873 |
872 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,651 |
1,239 |
$27K |
| D1120 |
Prophylaxis - child |
576 |
575 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,291 |
1,286 |
$15K |
| D1110 |
Prophylaxis - adult |
144 |
144 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
166 |
$11K |
| D0272 |
Bitewings - two radiographic images |
391 |
391 |
$5K |
| D0274 |
Bitewings - four radiographic images |
140 |
139 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
40 |
15 |
$3K |