| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
186 |
151 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
29 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$1K |
| D2140 |
|
26 |
16 |
$1K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$980.00 |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
84 |
$969.00 |
| D0120 |
Periodic oral evaluation - established patient |
52 |
51 |
$838.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
102 |
102 |
$614.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$546.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$325.00 |