| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,238 |
2,218 |
$118K |
| D1110 |
Prophylaxis - adult |
800 |
798 |
$67K |
| D1120 |
Prophylaxis - child |
1,645 |
1,641 |
$60K |
| D0274 |
Bitewings - four radiographic images |
1,364 |
1,362 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,650 |
1,645 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
200 |
200 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
67 |
38 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,059 |
375 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
89 |
$1K |
| D0272 |
Bitewings - two radiographic images |
74 |
74 |
$754.00 |