| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,948 |
1,907 |
$27K |
| D1120 |
Prophylaxis - child |
1,117 |
1,093 |
$26K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
447 |
251 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,571 |
1,544 |
$25K |
| D1351 |
Sealant - per tooth |
1,006 |
160 |
$20K |
| D1110 |
Prophylaxis - adult |
505 |
495 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
822 |
799 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
885 |
860 |
$9K |
| D0272 |
Bitewings - two radiographic images |
315 |
309 |
$5K |
| D0274 |
Bitewings - four radiographic images |
188 |
185 |
$4K |
| D2140 |
|
34 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
50 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$598.65 |