| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
59 |
59 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
138 |
138 |
$828.96 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
15 |
$813.29 |
| D0220 |
Intraoral - periapical first radiographic image |
112 |
111 |
$406.87 |
| D1120 |
Prophylaxis - child |
84 |
84 |
$376.52 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$246.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
66 |
$141.20 |