| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,744 |
576 |
$56K |
| D1999 |
|
2,847 |
2,367 |
$44K |
| D1120 |
Prophylaxis - child |
2,288 |
2,080 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,768 |
2,530 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,350 |
1,222 |
$27K |
| D0330 |
Panoramic radiographic image |
882 |
772 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,691 |
1,532 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,514 |
1,385 |
$21K |
| D1110 |
Prophylaxis - adult |
769 |
722 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,115 |
890 |
$17K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
404 |
180 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
835 |
767 |
$6K |
| D2140 |
|
171 |
68 |
$5K |
| D2160 |
|
19 |
12 |
$657.21 |