| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
862 |
860 |
$99K |
| D0220 |
Intraoral - periapical first radiographic image |
246 |
228 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
122 |
74 |
$8K |
| D2160 |
|
94 |
45 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$6K |
| D0274 |
Bitewings - four radiographic images |
376 |
376 |
$1K |
| D0330 |
Panoramic radiographic image |
113 |
113 |
$928.25 |
| D1120 |
Prophylaxis - child |
624 |
622 |
$805.13 |
| D0272 |
Bitewings - two radiographic images |
364 |
363 |
$763.55 |
| D2140 |
|
23 |
12 |
$549.05 |
| D1110 |
Prophylaxis - adult |
57 |
57 |
$489.15 |
| D1206 |
Topical application of fluoride varnish |
688 |
687 |
$208.65 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
14 |
$0.00 |