| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
84 |
83 |
$9K |
| D9248 |
|
14 |
12 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
12 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$4K |
| D1351 |
Sealant - per tooth |
80 |
14 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
25 |
13 |
$920.12 |
| D1120 |
Prophylaxis - child |
88 |
86 |
$235.69 |
| D1206 |
Topical application of fluoride varnish |
97 |
95 |
$170.61 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
36 |
$102.42 |
| D0274 |
Bitewings - four radiographic images |
31 |
27 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$0.00 |