| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
925 |
925 |
$42K |
| D1120 |
Prophylaxis - child |
860 |
859 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,143 |
1,142 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
197 |
197 |
$10K |
| D0274 |
Bitewings - four radiographic images |
500 |
500 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
183 |
183 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
53 |
29 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
739 |
359 |
$3K |
| D2140 |
|
21 |
12 |
$1K |
| D9430 |
|
13 |
13 |
$416.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$251.50 |
| D1999 |
|
74 |
63 |
$92.00 |
| D1203 |
|
12 |
12 |
$0.00 |