| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
892 |
890 |
$76K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
72 |
38 |
$7K |
| D1120 |
Prophylaxis - child |
797 |
795 |
$4K |
| D0272 |
Bitewings - two radiographic images |
554 |
554 |
$3K |
| D1206 |
Topical application of fluoride varnish |
814 |
814 |
$2K |
| D2140 |
|
15 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
59 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
55 |
55 |
$0.00 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$0.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$0.00 |