| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,234 |
1,231 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,815 |
1,810 |
$37K |
| D1110 |
Prophylaxis - adult |
704 |
701 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,533 |
1,529 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
469 |
453 |
$13K |
| D0274 |
Bitewings - four radiographic images |
388 |
385 |
$10K |
| D0272 |
Bitewings - two radiographic images |
431 |
431 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
110 |
79 |
$8K |
| D1351 |
Sealant - per tooth |
165 |
63 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
38 |
$4K |
| D0330 |
Panoramic radiographic image |
82 |
82 |
$4K |
| D2140 |
|
69 |
53 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
154 |
149 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
292 |
277 |
$3K |