| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,410 |
1,393 |
$74K |
| D1120 |
Prophylaxis - child |
1,056 |
1,040 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,235 |
1,225 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,596 |
1,580 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,877 |
1,680 |
$15K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
41 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
18 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
89 |
86 |
$966.00 |