| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,564 |
1,507 |
$34K |
| D1110 |
Prophylaxis - adult |
669 |
643 |
$29K |
| D1120 |
Prophylaxis - child |
849 |
824 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,027 |
991 |
$20K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$904.28 |
| D2140 |
|
17 |
12 |
$844.80 |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$699.60 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$366.84 |