| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
838 |
813 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
312 |
312 |
$69K |
| D1351 |
Sealant - per tooth |
1,655 |
382 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,135 |
1,105 |
$18K |
| D2140 |
|
305 |
195 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
200 |
117 |
$12K |
| D1120 |
Prophylaxis - child |
993 |
973 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
108 |
$7K |
| D1206 |
Topical application of fluoride varnish |
1,102 |
1,079 |
$1K |
| D1110 |
Prophylaxis - adult |
83 |
81 |
$806.29 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,865 |
1,004 |
$458.79 |
| D0274 |
Bitewings - four radiographic images |
464 |
459 |
$385.26 |
| D0272 |
Bitewings - two radiographic images |
312 |
306 |
$273.46 |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$0.00 |