| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
226 |
189 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
337 |
311 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
400 |
323 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
258 |
122 |
$13K |
| D2140 |
|
169 |
90 |
$9K |
| D1110 |
Prophylaxis - adult |
220 |
195 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,024 |
853 |
$7K |
| D0330 |
Panoramic radiographic image |
257 |
210 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,055 |
570 |
$4K |
| D0274 |
Bitewings - four radiographic images |
443 |
404 |
$3K |
| D1120 |
Prophylaxis - child |
331 |
297 |
$2K |
| D1206 |
Topical application of fluoride varnish |
447 |
398 |
$2K |
| D1351 |
Sealant - per tooth |
52 |
12 |
$969.67 |
| D0350 |
|
12 |
12 |
$110.84 |
| D0272 |
Bitewings - two radiographic images |
33 |
25 |
$0.00 |