| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
580 |
580 |
$31K |
| D1110 |
Prophylaxis - adult |
408 |
408 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,499 |
752 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
639 |
639 |
$7K |
| D0272 |
Bitewings - two radiographic images |
526 |
526 |
$6K |
| D2140 |
|
101 |
41 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
121 |
121 |
$5K |
| D1120 |
Prophylaxis - child |
114 |
114 |
$3K |
| D4341 |
|
47 |
12 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
34 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
176 |
175 |
$2K |
| D9430 |
|
25 |
25 |
$720.00 |