| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
689 |
685 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
618 |
613 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
747 |
741 |
$8K |
| D0274 |
Bitewings - four radiographic images |
893 |
887 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,156 |
1,115 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
268 |
125 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
806 |
795 |
$2K |
| D0330 |
Panoramic radiographic image |
216 |
216 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
226 |
226 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
108 |
108 |
$820.80 |
| D1120 |
Prophylaxis - child |
157 |
157 |
$691.20 |
| D2160 |
|
22 |
13 |
$590.20 |