| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,349 |
1,325 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,202 |
2,152 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
426 |
152 |
$35K |
| D1120 |
Prophylaxis - child |
1,076 |
1,052 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,480 |
1,446 |
$25K |
| D0330 |
Panoramic radiographic image |
354 |
345 |
$19K |
| D0274 |
Bitewings - four radiographic images |
475 |
471 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
370 |
356 |
$11K |
| D0272 |
Bitewings - two radiographic images |
408 |
393 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
191 |
$6K |
| D2140 |
|
102 |
56 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
34 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
51 |
27 |
$3K |
| D1351 |
Sealant - per tooth |
28 |
12 |
$697.76 |