| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
194 |
$10K |
| D1120 |
Prophylaxis - child |
288 |
285 |
$8K |
| D9430 |
|
118 |
112 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
49 |
26 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
72 |
72 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
330 |
326 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
50 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
475 |
290 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
127 |
$2K |
| D0350 |
|
81 |
55 |
$1K |
| D1351 |
Sealant - per tooth |
40 |
12 |
$836.00 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$669.60 |