| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,216 |
2,215 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
2,959 |
2,957 |
$78K |
| D1120 |
Prophylaxis - child |
616 |
616 |
$26K |
| D0330 |
Panoramic radiographic image |
616 |
614 |
$21K |
| D0274 |
Bitewings - four radiographic images |
737 |
737 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
208 |
131 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
170 |
157 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
913 |
913 |
$13K |
| D0272 |
Bitewings - two radiographic images |
271 |
271 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
258 |
258 |
$3K |
| D2140 |
|
41 |
40 |
$2K |
| D2160 |
|
25 |
25 |
$2K |
| D2335 |
|
14 |
13 |
$2K |
| D2331 |
|
15 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
16 |
12 |
$932.14 |