| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
170 |
167 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
191 |
189 |
$6K |
| D2140 |
|
72 |
48 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
43 |
28 |
$3K |
| D0274 |
Bitewings - four radiographic images |
110 |
108 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
156 |
$588.52 |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$433.20 |
| D1120 |
Prophylaxis - child |
181 |
180 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
192 |
191 |
$0.00 |