| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
631 |
610 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
448 |
444 |
$19K |
| D0274 |
Bitewings - four radiographic images |
196 |
194 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
35 |
26 |
$2K |
| D1120 |
Prophylaxis - child |
394 |
389 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
43 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
503 |
440 |
$800.08 |
| D2140 |
|
15 |
12 |
$700.62 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$352.49 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$160.32 |
| D1206 |
Topical application of fluoride varnish |
408 |
404 |
$89.36 |