| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,011 |
1,008 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,065 |
1,063 |
$29K |
| D0274 |
Bitewings - four radiographic images |
764 |
764 |
$21K |
| D1120 |
Prophylaxis - child |
142 |
140 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
302 |
301 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
89 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
127 |
124 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
14 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
27 |
$988.00 |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$860.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$146.30 |