| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
144 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
77 |
77 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
38 |
13 |
$4K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |
| D0274 |
Bitewings - four radiographic images |
189 |
189 |
$856.98 |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$455.49 |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
37 |
$228.37 |
| D1120 |
Prophylaxis - child |
61 |
60 |
$201.84 |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
226 |
$114.14 |
| D1206 |
Topical application of fluoride varnish |
136 |
136 |
$64.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
497 |
200 |
$0.00 |