| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
505 |
504 |
$32K |
| D1110 |
Prophylaxis - adult |
267 |
267 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
170 |
$11K |
| D1206 |
Topical application of fluoride varnish |
364 |
364 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
104 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
751 |
209 |
$3K |
| D1120 |
Prophylaxis - child |
99 |
97 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
41 |
24 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
201 |
196 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
13 |
$1K |
| D9430 |
|
25 |
24 |
$637.00 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
49 |
$624.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$280.80 |