| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,838 |
2,820 |
$159K |
| D1120 |
Prophylaxis - child |
3,315 |
3,293 |
$131K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
576 |
441 |
$38K |
| D2140 |
|
681 |
478 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,286 |
1,284 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,456 |
1,448 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,848 |
2,412 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,720 |
1,718 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
291 |
165 |
$16K |
| D1310 |
|
206 |
201 |
$9K |
| D0272 |
Bitewings - two radiographic images |
593 |
592 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
68 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$858.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |
| D0603 |
|
31 |
30 |
$450.00 |
| D9430 |
|
13 |
12 |
$416.00 |
| D0602 |
|
12 |
12 |
$180.00 |