| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
431 |
425 |
$17K |
| D1110 |
Prophylaxis - adult |
132 |
132 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
169 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
177 |
177 |
$8K |
| D0274 |
Bitewings - four radiographic images |
196 |
193 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
986 |
508 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
51 |
27 |
$3K |
| D1120 |
Prophylaxis - child |
80 |
76 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$261.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
12 |
$140.00 |