| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
582 |
481 |
$22K |
| D1110 |
Prophylaxis - adult |
340 |
340 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
576 |
571 |
$13K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
39 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$1K |
| D1206 |
Topical application of fluoride varnish |
81 |
80 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
64 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
12 |
$233.32 |