| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,111 |
4,097 |
$177K |
| D0120 |
Periodic oral evaluation - established patient |
1,518 |
1,503 |
$163K |
| D0272 |
Bitewings - two radiographic images |
903 |
893 |
$31K |
| D1206 |
Topical application of fluoride varnish |
3,931 |
3,920 |
$30K |
| D1351 |
Sealant - per tooth |
454 |
65 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,271 |
1,251 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,437 |
1,147 |
$5K |
| D0274 |
Bitewings - four radiographic images |
196 |
196 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
72 |
33 |
$2K |
| D0330 |
Panoramic radiographic image |
68 |
68 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
136 |
133 |
$0.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$0.00 |