| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
627 |
620 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,110 |
1,103 |
$22K |
| D1206 |
Topical application of fluoride varnish |
544 |
543 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,018 |
870 |
$8K |
| D0274 |
Bitewings - four radiographic images |
289 |
289 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,302 |
527 |
$7K |
| D2140 |
|
86 |
58 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
180 |
179 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
37 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D1120 |
Prophylaxis - child |
95 |
95 |
$1K |