| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,807 |
1,784 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
2,414 |
2,382 |
$71K |
| D1120 |
Prophylaxis - child |
1,023 |
1,013 |
$40K |
| D1351 |
Sealant - per tooth |
1,272 |
170 |
$36K |
| D0274 |
Bitewings - four radiographic images |
764 |
757 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,054 |
1,044 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
636 |
636 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
399 |
372 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
147 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
94 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
13 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
15 |
$786.40 |