| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,711 |
2,629 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,427 |
2,423 |
$54K |
| D1120 |
Prophylaxis - child |
1,777 |
1,775 |
$46K |
| D1351 |
Sealant - per tooth |
1,794 |
397 |
$44K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
526 |
274 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,273 |
1,271 |
$16K |
| D0274 |
Bitewings - four radiographic images |
925 |
924 |
$16K |
| D1110 |
Prophylaxis - adult |
458 |
457 |
$15K |
| D1999 |
|
957 |
937 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
26 |
$3K |
| D2140 |
|
39 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
270 |
267 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
15 |
$83.20 |
| D0602 |
|
26 |
26 |
$0.00 |