| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,088 |
5,253 |
$115K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,086 |
6,108 |
$100K |
| D1999 |
|
5,720 |
5,130 |
$86K |
| D1351 |
Sealant - per tooth |
5,674 |
866 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,076 |
2,669 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
3,927 |
3,400 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
969 |
579 |
$41K |
| D0272 |
Bitewings - two radiographic images |
2,755 |
2,416 |
$39K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,008 |
443 |
$35K |
| D1110 |
Prophylaxis - adult |
729 |
628 |
$20K |
| D0330 |
Panoramic radiographic image |
480 |
435 |
$15K |
| D2140 |
|
242 |
158 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
375 |
361 |
$3K |
| D2160 |
|
16 |
12 |
$489.60 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$250.68 |