| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
366 |
328 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
240 |
222 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
183 |
176 |
$19K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
126 |
67 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
70 |
68 |
$842.91 |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$364.09 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
14 |
$227.85 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$135.51 |
| D9211 |
|
20 |
14 |
$0.00 |
| D1120 |
Prophylaxis - child |
31 |
31 |
$0.00 |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$0.00 |