| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$1K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$1K |
| D9110 |
|
28 |
26 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
15 |
$740.00 |
| D0120 |
Periodic oral evaluation - established patient |
35 |
35 |
$718.20 |
| D2140 |
|
25 |
15 |
$700.00 |
| D1110 |
Prophylaxis - adult |
20 |
20 |
$600.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$450.19 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
28 |
$300.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
23 |
$240.00 |