| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
224 |
221 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
290 |
286 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
81 |
47 |
$7K |
| D1120 |
Prophylaxis - child |
101 |
99 |
$5K |
| D0274 |
Bitewings - four radiographic images |
137 |
134 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
116 |
$4K |
| D1206 |
Topical application of fluoride varnish |
130 |
128 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
65 |
$3K |
| D0330 |
Panoramic radiographic image |
50 |
48 |
$2K |
| D2140 |
|
26 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
66 |
$937.02 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$410.80 |