| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
591 |
591 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
777 |
777 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
277 |
172 |
$15K |
| D0274 |
Bitewings - four radiographic images |
467 |
467 |
$13K |
| D1351 |
Sealant - per tooth |
418 |
46 |
$10K |
| D2140 |
|
217 |
129 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
812 |
811 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
683 |
662 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
91 |
91 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$840.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$585.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$400.00 |
| D0270 |
|
13 |
13 |
$96.00 |