| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
521 |
518 |
$9K |
| D1110 |
Prophylaxis - adult |
240 |
240 |
$7K |
| D1120 |
Prophylaxis - child |
219 |
217 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
116 |
66 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
39 |
$2K |
| D0274 |
Bitewings - four radiographic images |
104 |
103 |
$982.41 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$0.00 |