| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
510 |
403 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
320 |
150 |
$7K |
| D2140 |
|
301 |
100 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
314 |
246 |
$3K |
| D1999 |
|
303 |
249 |
$3K |
| D0330 |
Panoramic radiographic image |
103 |
70 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
406 |
253 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
71 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
126 |
$634.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
44 |
$596.64 |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$359.42 |