| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
153 |
153 |
$17K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
69 |
34 |
$4K |
| D1351 |
Sealant - per tooth |
58 |
15 |
$2K |
| D2140 |
|
15 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
113 |
$1K |
| D1120 |
Prophylaxis - child |
133 |
133 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$223.02 |
| D0272 |
Bitewings - two radiographic images |
62 |
62 |
$178.52 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
125 |
125 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
103 |
99 |
$0.00 |