| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
681 |
675 |
$10K |
| D1110 |
Prophylaxis - adult |
191 |
190 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
104 |
81 |
$5K |
| D1120 |
Prophylaxis - child |
240 |
236 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
149 |
$4K |
| D1354 |
|
392 |
102 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
215 |
212 |
$4K |
| D1351 |
Sealant - per tooth |
217 |
57 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
146 |
140 |
$3K |
| D0330 |
Panoramic radiographic image |
58 |
57 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
136 |
63 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
169 |
164 |
$889.48 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$420.00 |