| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
197 |
195 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
75 |
34 |
$4K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
418 |
411 |
$2K |
| D1351 |
Sealant - per tooth |
91 |
17 |
$1K |
| D2140 |
|
31 |
15 |
$690.86 |
| D0274 |
Bitewings - four radiographic images |
185 |
185 |
$149.78 |
| D1206 |
Topical application of fluoride varnish |
199 |
198 |
$14.77 |
| D1120 |
Prophylaxis - child |
80 |
79 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
611 |
348 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$0.00 |