| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
406 |
391 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
308 |
296 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
506 |
482 |
$9K |
| D0274 |
Bitewings - four radiographic images |
339 |
326 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
63 |
29 |
$5K |
| D1120 |
Prophylaxis - child |
90 |
87 |
$5K |
| D1206 |
Topical application of fluoride varnish |
92 |
88 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
103 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
482 |
394 |
$3K |
| D2160 |
|
20 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$580.00 |
| D1110 |
Prophylaxis - adult |
31 |
26 |
$500.00 |
| D0601 |
|
60 |
59 |
$290.00 |