| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
297 |
297 |
$11K |
| D1120 |
Prophylaxis - child |
322 |
322 |
$11K |
| D0274 |
Bitewings - four radiographic images |
152 |
152 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
88 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
179 |
$3K |
| D0272 |
Bitewings - two radiographic images |
104 |
104 |
$3K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
44 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
57 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
384 |
384 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
26 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
16 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
33 |
$537.75 |