| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
677 |
677 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
258 |
257 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,113 |
964 |
$13K |
| D0274 |
Bitewings - four radiographic images |
654 |
654 |
$12K |
| D1110 |
Prophylaxis - adult |
106 |
106 |
$8K |
| D1120 |
Prophylaxis - child |
236 |
236 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
163 |
163 |
$7K |
| D1206 |
Topical application of fluoride varnish |
520 |
520 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
68 |
42 |
$5K |
| D4910 |
|
17 |
17 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
82 |
82 |
$829.50 |
| D0350 |
|
79 |
51 |
$700.80 |