| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
592 |
580 |
$15K |
| D1110 |
Prophylaxis - adult |
232 |
228 |
$10K |
| D1120 |
Prophylaxis - child |
220 |
209 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
57 |
$4K |
| D1206 |
Topical application of fluoride varnish |
146 |
144 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
24 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$869.20 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$415.15 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
17 |
$142.50 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$103.50 |