| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,268 |
585 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
1,506 |
1,506 |
$117K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,698 |
1,673 |
$110K |
| D1110 |
Prophylaxis - adult |
1,238 |
1,231 |
$108K |
| D1120 |
Prophylaxis - child |
1,949 |
1,929 |
$100K |
| D0210 |
Intraoral - complete series of radiographic images |
1,510 |
1,487 |
$71K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,252 |
2,054 |
$37K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
520 |
351 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,883 |
1,882 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,106 |
1,906 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,250 |
1,224 |
$19K |
| D9430 |
|
586 |
537 |
$19K |
| D0274 |
Bitewings - four radiographic images |
831 |
831 |
$18K |
| D2140 |
|
101 |
67 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
51 |
$5K |
| D2160 |
|
24 |
15 |
$2K |
| D1310 |
|
25 |
25 |
$966.00 |
| D0601 |
|
49 |
49 |
$540.00 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$336.00 |