| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,298 |
2,285 |
$182K |
| D1120 |
Prophylaxis - child |
2,325 |
2,317 |
$28K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
261 |
117 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
131 |
131 |
$14K |
| D1206 |
Topical application of fluoride varnish |
2,465 |
2,457 |
$12K |
| D2140 |
|
201 |
108 |
$10K |
| D0272 |
Bitewings - two radiographic images |
1,252 |
1,242 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,049 |
1,037 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
42 |
$9K |
| D1351 |
Sealant - per tooth |
129 |
28 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
897 |
853 |
$5K |
| D0274 |
Bitewings - four radiographic images |
97 |
97 |
$2K |