| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
691 |
691 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
640 |
640 |
$94K |
| D1351 |
Sealant - per tooth |
2,682 |
725 |
$21K |
| D1120 |
Prophylaxis - child |
1,503 |
1,503 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,088 |
1,419 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
283 |
148 |
$8K |
| D1206 |
Topical application of fluoride varnish |
1,530 |
1,530 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,420 |
1,420 |
$6K |
| D0272 |
Bitewings - two radiographic images |
554 |
554 |
$4K |
| D2140 |
|
130 |
90 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
416 |
416 |
$1K |
| D2160 |
|
14 |
14 |
$111.20 |