| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,271 |
1,264 |
$77K |
| D1110 |
Prophylaxis - adult |
758 |
755 |
$66K |
| D1120 |
Prophylaxis - child |
798 |
796 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
536 |
536 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,178 |
1,171 |
$14K |
| D1206 |
Topical application of fluoride varnish |
752 |
747 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,052 |
1,538 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
238 |
238 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
140 |
67 |
$9K |
| D2791 |
|
14 |
13 |
$7K |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$3K |
| D4910 |
|
41 |
41 |
$3K |
| D4341 |
|
35 |
12 |
$2K |
| D2954 |
|
13 |
12 |
$1K |
| D0350 |
|
15 |
12 |
$230.40 |
| D1310 |
|
20 |
20 |
$0.00 |