| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,514 |
837 |
$111K |
| D1120 |
Prophylaxis - child |
1,893 |
1,853 |
$82K |
| D1206 |
Topical application of fluoride varnish |
1,736 |
1,695 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,361 |
1,321 |
$43K |
| D0330 |
Panoramic radiographic image |
1,083 |
1,042 |
$42K |
| D0274 |
Bitewings - four radiographic images |
924 |
914 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
638 |
621 |
$21K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
342 |
207 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,312 |
1,272 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
321 |
214 |
$13K |
| D0272 |
Bitewings - two radiographic images |
701 |
671 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
488 |
485 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,913 |
1,274 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
48 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
158 |
158 |
$2K |
| D2140 |
|
20 |
12 |
$1K |
| D0601 |
|
63 |
60 |
$230.00 |
| D0602 |
|
27 |
25 |
$95.00 |
| D0603 |
|
15 |
12 |
$20.00 |