| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,964 |
1,962 |
$149K |
| D1120 |
Prophylaxis - child |
2,121 |
2,120 |
$29K |
| D1351 |
Sealant - per tooth |
785 |
154 |
$24K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
250 |
130 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
164 |
164 |
$14K |
| D1206 |
Topical application of fluoride varnish |
2,204 |
2,203 |
$14K |
| D2140 |
|
255 |
131 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,101 |
1,097 |
$8K |
| D0272 |
Bitewings - two radiographic images |
1,081 |
1,079 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
946 |
904 |
$4K |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$288.88 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$0.00 |