| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,739 |
1,739 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
1,964 |
1,963 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,460 |
1,460 |
$32K |
| D1110 |
Prophylaxis - adult |
502 |
501 |
$25K |
| D1206 |
Topical application of fluoride varnish |
732 |
731 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
234 |
137 |
$18K |
| D0274 |
Bitewings - four radiographic images |
326 |
326 |
$11K |
| D1351 |
Sealant - per tooth |
280 |
32 |
$9K |
| D2140 |
|
127 |
76 |
$8K |
| D0272 |
Bitewings - two radiographic images |
296 |
296 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
307 |
303 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
14 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
55 |
$595.51 |