| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
488 |
488 |
$45K |
| D1120 |
Prophylaxis - child |
516 |
514 |
$5K |
| D1351 |
Sealant - per tooth |
72 |
17 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
359 |
357 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
24 |
18 |
$1K |
| D1206 |
Topical application of fluoride varnish |
555 |
552 |
$621.25 |
| D0272 |
Bitewings - two radiographic images |
189 |
188 |
$160.42 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$54.89 |
| D0230 |
Intraoral - periapical each additional radiographic image |
307 |
287 |
$23.56 |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$0.00 |