| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
597 |
494 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
834 |
699 |
$11K |
| D1120 |
Prophylaxis - child |
482 |
401 |
$7K |
| D1206 |
Topical application of fluoride varnish |
782 |
642 |
$6K |
| D0274 |
Bitewings - four radiographic images |
433 |
356 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
969 |
765 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
345 |
269 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
357 |
278 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
79 |
65 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
683 |
513 |
$3K |
| D0272 |
Bitewings - two radiographic images |
89 |
73 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
26 |
$649.35 |
| D1351 |
Sealant - per tooth |
49 |
12 |
$371.80 |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$107.25 |
| D1330 |
|
1,765 |
1,237 |
$0.00 |
| D0603 |
|
410 |
301 |
$0.00 |
| D0601 |
|
44 |
29 |
$0.00 |
| D0602 |
|
21 |
12 |
$0.00 |
| D1354 |
|
855 |
269 |
$0.00 |