| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,161 |
2,158 |
$213K |
| D1120 |
Prophylaxis - child |
2,174 |
2,170 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,322 |
1,322 |
$22K |
| D1206 |
Topical application of fluoride varnish |
2,128 |
2,128 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,640 |
1,637 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,968 |
1,571 |
$14K |
| D1351 |
Sealant - per tooth |
518 |
103 |
$13K |
| D0330 |
Panoramic radiographic image |
323 |
323 |
$8K |
| D0274 |
Bitewings - four radiographic images |
302 |
302 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
25 |
$2K |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$764.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$0.00 |