| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,743 |
1,724 |
$86K |
| D1120 |
Prophylaxis - child |
2,050 |
2,039 |
$75K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,083 |
2,067 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,507 |
758 |
$6K |
| D0274 |
Bitewings - four radiographic images |
245 |
243 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
42 |
24 |
$3K |
| D2140 |
|
19 |
12 |
$982.80 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$792.00 |
| D0272 |
Bitewings - two radiographic images |
65 |
65 |
$754.00 |