| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
501 |
500 |
$59K |
| D0272 |
Bitewings - two radiographic images |
380 |
379 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
226 |
$18K |
| D2160 |
|
208 |
100 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
185 |
105 |
$11K |
| D1120 |
Prophylaxis - child |
483 |
482 |
$3K |
| D9420 |
|
15 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
133 |
132 |
$2K |
| D2161 |
|
20 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$528.49 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
14 |
$256.15 |
| D1206 |
Topical application of fluoride varnish |
457 |
456 |
$62.92 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |