| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
537 |
535 |
$32K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
137 |
59 |
$9K |
| D1120 |
Prophylaxis - child |
208 |
208 |
$7K |
| D4341 |
|
96 |
26 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
138 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
388 |
388 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
786 |
337 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
48 |
48 |
$3K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$3K |
| D2954 |
|
21 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
73 |
73 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$0.00 |