| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
806 |
623 |
$18K |
| D1351 |
Sealant - per tooth |
1,007 |
132 |
$13K |
| D2140 |
|
587 |
253 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
827 |
643 |
$11K |
| D1120 |
Prophylaxis - child |
602 |
472 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
429 |
244 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
921 |
706 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
487 |
380 |
$7K |
| D0272 |
Bitewings - two radiographic images |
571 |
498 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
164 |
89 |
$6K |
| D0330 |
Panoramic radiographic image |
233 |
232 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
112 |
63 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$336.30 |