| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,707 |
1,707 |
$70K |
| D1120 |
Prophylaxis - child |
1,811 |
1,809 |
$55K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
558 |
314 |
$37K |
| D1110 |
Prophylaxis - adult |
342 |
341 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,387 |
2,385 |
$23K |
| D0274 |
Bitewings - four radiographic images |
854 |
853 |
$18K |
| D1351 |
Sealant - per tooth |
606 |
156 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,938 |
874 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$7K |
| D0272 |
Bitewings - two radiographic images |
439 |
438 |
$5K |
| D2140 |
|
67 |
56 |
$4K |
| D2160 |
|
36 |
26 |
$3K |