| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
756 |
669 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
704 |
663 |
$81K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
426 |
193 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
74 |
$12K |
| D0274 |
Bitewings - four radiographic images |
833 |
768 |
$6K |
| D2140 |
|
21 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
255 |
245 |
$1K |
| D1110 |
Prophylaxis - adult |
330 |
311 |
$698.75 |
| D2160 |
|
18 |
12 |
$696.86 |
| D1206 |
Topical application of fluoride varnish |
370 |
351 |
$126.00 |
| D0330 |
Panoramic radiographic image |
59 |
58 |
$75.91 |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
182 |
$70.44 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$0.00 |