| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1999 |
|
3,318 |
2,510 |
$51K |
| D1120 |
Prophylaxis - child |
2,365 |
1,923 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,036 |
2,463 |
$42K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
609 |
299 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,714 |
1,422 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
750 |
632 |
$13K |
| D2140 |
|
252 |
113 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
250 |
104 |
$7K |
| D1110 |
Prophylaxis - adult |
239 |
195 |
$6K |
| D0272 |
Bitewings - two radiographic images |
355 |
275 |
$5K |
| D1351 |
Sealant - per tooth |
300 |
30 |
$5K |
| D0330 |
Panoramic radiographic image |
136 |
113 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
201 |
102 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
66 |
$505.84 |