| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
749 |
749 |
$32K |
| D1120 |
Prophylaxis - child |
601 |
601 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
995 |
995 |
$10K |
| D0274 |
Bitewings - four radiographic images |
85 |
85 |
$2K |
| D2140 |
|
29 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
295 |
121 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
97 |
97 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$1K |
| D0350 |
|
43 |
27 |
$518.40 |
| D9430 |
|
15 |
14 |
$480.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$168.00 |
| D1330 |
|
20 |
20 |
$0.00 |