| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
444 |
425 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
643 |
623 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
378 |
367 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
136 |
129 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
12 |
$4K |
| D0274 |
Bitewings - four radiographic images |
126 |
118 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
48 |
27 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
81 |
$950.17 |
| D1120 |
Prophylaxis - child |
29 |
29 |
$621.00 |
| D1206 |
Topical application of fluoride varnish |
20 |
19 |
$503.12 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$479.25 |
| D1351 |
Sealant - per tooth |
54 |
12 |
$146.75 |