| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,646 |
624 |
$102K |
| D1110 |
Prophylaxis - adult |
2,277 |
1,951 |
$65K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,669 |
3,122 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,466 |
2,074 |
$47K |
| D0274 |
Bitewings - four radiographic images |
2,491 |
2,149 |
$40K |
| D1120 |
Prophylaxis - child |
1,449 |
1,207 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,557 |
1,425 |
$28K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
347 |
174 |
$19K |
| D1999 |
|
2,455 |
1,767 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,147 |
977 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
351 |
310 |
$6K |
| D0330 |
Panoramic radiographic image |
114 |
114 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
297 |
247 |
$1K |
| D2140 |
|
31 |
12 |
$841.68 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$596.62 |