| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,381 |
1,368 |
$136K |
| D1120 |
Prophylaxis - child |
1,512 |
1,484 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,150 |
1,136 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
53 |
13 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
836 |
824 |
$3K |
| D1206 |
Topical application of fluoride varnish |
1,399 |
1,377 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
697 |
689 |
$346.17 |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$49.67 |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
81 |
$19.00 |
| D0274 |
Bitewings - four radiographic images |
85 |
85 |
$0.00 |
| D0330 |
Panoramic radiographic image |
50 |
49 |
$0.00 |