| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2160 |
|
921 |
614 |
$91K |
| D1351 |
Sealant - per tooth |
1,315 |
323 |
$56K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
683 |
420 |
$54K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
328 |
230 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
885 |
885 |
$28K |
| D2161 |
|
114 |
97 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
886 |
880 |
$10K |
| D0272 |
Bitewings - two radiographic images |
413 |
413 |
$6K |
| D0274 |
Bitewings - four radiographic images |
216 |
216 |
$6K |
| D2335 |
|
38 |
27 |
$6K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$3K |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
123 |
123 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
90 |
$471.00 |