| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,001 |
1,001 |
$76K |
| D1120 |
Prophylaxis - child |
817 |
816 |
$42K |
| D1110 |
Prophylaxis - adult |
367 |
367 |
$33K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
403 |
228 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,435 |
1,434 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
211 |
211 |
$13K |
| D2740 |
Crown - porcelain/ceramic |
19 |
18 |
$9K |
| D0274 |
Bitewings - four radiographic images |
391 |
391 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
95 |
95 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
602 |
220 |
$2K |
| D2160 |
|
29 |
16 |
$2K |
| D1351 |
Sealant - per tooth |
62 |
15 |
$2K |
| D2140 |
|
20 |
12 |
$1K |