| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
238 |
226 |
$9K |
| D1120 |
Prophylaxis - child |
210 |
196 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
363 |
359 |
$7K |
| D0274 |
Bitewings - four radiographic images |
205 |
193 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
152 |
145 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
104 |
55 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
157 |
$4K |
| D1206 |
Topical application of fluoride varnish |
284 |
269 |
$4K |
| D0330 |
Panoramic radiographic image |
29 |
26 |
$897.80 |
| D2160 |
|
18 |
12 |
$864.84 |
| D0220 |
Intraoral - periapical first radiographic image |
98 |
89 |
$699.93 |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
14 |
$662.16 |
| D0272 |
Bitewings - two radiographic images |
29 |
24 |
$385.56 |
| D0431 |
|
243 |
227 |
$355.00 |