| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
192 |
192 |
$14K |
| D9430 |
|
299 |
246 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,181 |
663 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
578 |
483 |
$6K |
| D1206 |
Topical application of fluoride varnish |
281 |
280 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
50 |
25 |
$3K |
| D2140 |
|
41 |
14 |
$2K |
| D0350 |
|
127 |
45 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$682.50 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$216.00 |