| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
651 |
650 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
995 |
990 |
$13K |
| D1120 |
Prophylaxis - child |
345 |
344 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,285 |
673 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
129 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
114 |
114 |
$5K |
| D0350 |
|
484 |
190 |
$4K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
25 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
72 |
72 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$306.00 |