| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
918 |
819 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
958 |
859 |
$25K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
436 |
319 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
907 |
808 |
$22K |
| D0274 |
Bitewings - four radiographic images |
380 |
329 |
$6K |
| D2140 |
|
178 |
138 |
$6K |
| D2160 |
|
54 |
36 |
$3K |
| D1351 |
Sealant - per tooth |
51 |
20 |
$3K |
| D1110 |
Prophylaxis - adult |
60 |
45 |
$2K |
| D0330 |
Panoramic radiographic image |
90 |
71 |
$2K |
| D0272 |
Bitewings - two radiographic images |
106 |
95 |
$968.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
31 |
$715.70 |