| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,576 |
2,573 |
$150K |
| D1110 |
Prophylaxis - adult |
1,570 |
1,568 |
$133K |
| D1120 |
Prophylaxis - child |
1,656 |
1,653 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,327 |
2,422 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
792 |
790 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,255 |
2,250 |
$28K |
| D4910 |
|
300 |
300 |
$23K |
| D0274 |
Bitewings - four radiographic images |
908 |
908 |
$19K |
| D0272 |
Bitewings - two radiographic images |
987 |
987 |
$12K |
| D0350 |
|
597 |
201 |
$6K |
| D2140 |
|
105 |
38 |
$6K |
| D0330 |
Panoramic radiographic image |
179 |
179 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
66 |
41 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
14 |
$2K |