| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
554 |
546 |
$44K |
| D1120 |
Prophylaxis - child |
545 |
538 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
138 |
76 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
49 |
$6K |
| D2140 |
|
75 |
54 |
$4K |
| D1351 |
Sealant - per tooth |
91 |
19 |
$3K |
| D1206 |
Topical application of fluoride varnish |
613 |
603 |
$464.00 |
| D0220 |
Intraoral - periapical first radiographic image |
351 |
344 |
$404.95 |
| D0230 |
Intraoral - periapical each additional radiographic image |
335 |
314 |
$55.53 |
| D0272 |
Bitewings - two radiographic images |
183 |
177 |
$19.90 |
| D0274 |
Bitewings - four radiographic images |
116 |
112 |
$0.00 |
| D1110 |
Prophylaxis - adult |
33 |
33 |
$0.00 |