| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,652 |
1,642 |
$91K |
| D1110 |
Prophylaxis - adult |
715 |
711 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,787 |
1,772 |
$38K |
| D1120 |
Prophylaxis - child |
939 |
930 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,152 |
2,574 |
$30K |
| D9430 |
|
853 |
762 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,596 |
1,580 |
$20K |
| D0350 |
|
791 |
434 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
85 |
52 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$5K |
| D1206 |
Topical application of fluoride varnish |
277 |
277 |
$5K |
| D4341 |
|
53 |
14 |
$4K |
| D2140 |
|
19 |
13 |
$873.60 |
| D1320 |
|
50 |
50 |
$867.50 |
| D1351 |
Sealant - per tooth |
42 |
12 |
$858.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |