| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,591 |
1,582 |
$79K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
767 |
355 |
$51K |
| D1120 |
Prophylaxis - child |
1,104 |
1,100 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,853 |
1,842 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,541 |
1,808 |
$18K |
| D1110 |
Prophylaxis - adult |
203 |
203 |
$16K |
| D0274 |
Bitewings - four radiographic images |
869 |
866 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
252 |
251 |
$11K |
| D1351 |
Sealant - per tooth |
427 |
130 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
752 |
696 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$2K |
| D0272 |
Bitewings - two radiographic images |
132 |
132 |
$1K |
| D9430 |
|
43 |
40 |
$1K |
| D2140 |
|
14 |
12 |
$764.40 |