| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
539 |
538 |
$76K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
180 |
81 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
715 |
699 |
$3K |
| D1120 |
Prophylaxis - child |
295 |
294 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
359 |
357 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,343 |
567 |
$630.97 |
| D1110 |
Prophylaxis - adult |
32 |
31 |
$212.68 |
| D1206 |
Topical application of fluoride varnish |
383 |
382 |
$201.12 |