| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
153 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
98 |
32 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,707 |
429 |
$6K |
| D1120 |
Prophylaxis - child |
163 |
159 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
189 |
169 |
$4K |
| D0274 |
Bitewings - four radiographic images |
200 |
196 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
24 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
152 |
148 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$768.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |