| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,176 |
1,154 |
$33K |
| D1999 |
|
931 |
885 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
820 |
801 |
$10K |
| D0272 |
Bitewings - two radiographic images |
658 |
647 |
$9K |
| D0330 |
Panoramic radiographic image |
272 |
268 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
335 |
331 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
170 |
108 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
216 |
216 |
$3K |
| D2140 |
|
110 |
70 |
$2K |
| D1120 |
Prophylaxis - child |
90 |
90 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
17 |
$519.31 |