| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,249 |
1,227 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,591 |
1,563 |
$36K |
| D0274 |
Bitewings - four radiographic images |
639 |
627 |
$22K |
| D1120 |
Prophylaxis - child |
372 |
368 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
394 |
390 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
255 |
240 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
133 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
16 |
14 |
$1K |
| D2140 |
|
17 |
15 |
$914.36 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$565.00 |
| D9110 |
|
12 |
12 |
$405.00 |