| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
246 |
245 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
119 |
119 |
$19K |
| D1351 |
Sealant - per tooth |
536 |
133 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
23 |
15 |
$821.02 |
| D2140 |
|
24 |
19 |
$395.10 |
| D0220 |
Intraoral - periapical first radiographic image |
377 |
375 |
$237.54 |
| D1120 |
Prophylaxis - child |
437 |
435 |
$184.78 |
| D0274 |
Bitewings - four radiographic images |
97 |
97 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
444 |
442 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
78 |
76 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,173 |
374 |
$0.00 |