| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,984 |
5,693 |
$116K |
| D1120 |
Prophylaxis - child |
2,898 |
2,740 |
$82K |
| D1110 |
Prophylaxis - adult |
1,875 |
1,801 |
$68K |
| D1206 |
Topical application of fluoride varnish |
3,225 |
3,085 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,024 |
991 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
773 |
723 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
122 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
127 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
22 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
59 |
26 |
$444.06 |