| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
776 |
770 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,063 |
1,056 |
$13K |
| D0350 |
|
1,571 |
500 |
$12K |
| D0274 |
Bitewings - four radiographic images |
564 |
558 |
$12K |
| D1120 |
Prophylaxis - child |
283 |
283 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,217 |
1,088 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
123 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
39 |
$5K |
| D4910 |
|
64 |
64 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
12 |
$1K |
| D1999 |
|
101 |
87 |
$180.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |