| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
301 |
265 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
268 |
248 |
$4K |
| D1999 |
|
139 |
114 |
$2K |
| D0272 |
Bitewings - two radiographic images |
146 |
140 |
$2K |
| D2140 |
|
89 |
41 |
$2K |
| D1351 |
Sealant - per tooth |
103 |
16 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
96 |
93 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
310 |
70 |
$1K |
| D1120 |
Prophylaxis - child |
43 |
42 |
$680.40 |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
14 |
$495.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$432.04 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
15 |
$425.40 |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
60 |
$324.00 |
| D0120 |
Periodic oral evaluation - established patient |
22 |
18 |
$178.20 |