| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,142 |
1,134 |
$62K |
| D1110 |
Prophylaxis - adult |
343 |
343 |
$26K |
| D1120 |
Prophylaxis - child |
536 |
536 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,087 |
1,074 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,513 |
1,508 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
228 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
61 |
27 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
189 |
$2K |
| D0272 |
Bitewings - two radiographic images |
117 |
117 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$1K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$280.80 |