| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
867 |
839 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
400 |
215 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,020 |
984 |
$15K |
| D1999 |
|
1,004 |
940 |
$14K |
| D1351 |
Sealant - per tooth |
773 |
144 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
535 |
522 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
213 |
102 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
499 |
475 |
$7K |
| D0272 |
Bitewings - two radiographic images |
395 |
379 |
$6K |
| D0330 |
Panoramic radiographic image |
192 |
185 |
$6K |
| D1110 |
Prophylaxis - adult |
112 |
105 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
259 |
120 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
39 |
$893.54 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$181.20 |