| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
888 |
888 |
$92K |
| D1351 |
Sealant - per tooth |
444 |
86 |
$16K |
| D2140 |
|
59 |
43 |
$3K |
| D1206 |
Topical application of fluoride varnish |
826 |
826 |
$2K |
| D0272 |
Bitewings - two radiographic images |
711 |
710 |
$2K |
| D1120 |
Prophylaxis - child |
848 |
847 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
17 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$885.88 |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
156 |
$470.17 |
| D1110 |
Prophylaxis - adult |
48 |
48 |
$115.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
57 |
$94.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
45 |
$0.00 |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$0.00 |