| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,489 |
1,487 |
$36K |
| D1110 |
Prophylaxis - adult |
878 |
876 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,177 |
1,177 |
$13K |
| D1120 |
Prophylaxis - child |
425 |
425 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
323 |
322 |
$11K |
| D0272 |
Bitewings - two radiographic images |
1,039 |
1,039 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,302 |
1,302 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
628 |
628 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
85 |
49 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
156 |
$4K |
| D2140 |
|
39 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$624.00 |
| D9920 |
|
15 |
13 |
$450.00 |
| D0603 |
|
39 |
39 |
$390.00 |
| D0191 |
|
14 |
14 |
$345.00 |
| D1330 |
|
793 |
786 |
$0.00 |