| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
550 |
547 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
263 |
262 |
$15K |
| D1120 |
Prophylaxis - child |
500 |
498 |
$15K |
| D1110 |
Prophylaxis - adult |
174 |
174 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,613 |
991 |
$11K |
| D0274 |
Bitewings - four radiographic images |
532 |
529 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
482 |
480 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
43 |
26 |
$3K |
| D0350 |
|
246 |
126 |
$3K |
| D2140 |
|
41 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
27 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$1K |
| D1351 |
Sealant - per tooth |
54 |
18 |
$1K |