| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,657 |
2,655 |
$71K |
| D1110 |
Prophylaxis - adult |
1,369 |
1,369 |
$71K |
| D1120 |
Prophylaxis - child |
1,451 |
1,449 |
$55K |
| D1206 |
Topical application of fluoride varnish |
1,588 |
1,586 |
$38K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
281 |
169 |
$22K |
| D2140 |
|
73 |
58 |
$5K |
| D0274 |
Bitewings - four radiographic images |
141 |
141 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
27 |
$3K |
| D0272 |
Bitewings - two radiographic images |
137 |
137 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
108 |
108 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
138 |
$2K |
| D1351 |
Sealant - per tooth |
35 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$516.00 |