| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
818 |
814 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
395 |
124 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
761 |
759 |
$15K |
| D0272 |
Bitewings - two radiographic images |
533 |
531 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
114 |
77 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
318 |
318 |
$6K |
| D0330 |
Panoramic radiographic image |
125 |
123 |
$5K |
| D2140 |
|
97 |
69 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
152 |
$3K |
| D1351 |
Sealant - per tooth |
116 |
19 |
$3K |
| D1120 |
Prophylaxis - child |
90 |
90 |
$3K |
| D0601 |
|
117 |
117 |
$1K |
| D1330 |
|
160 |
160 |
$790.00 |
| D1310 |
|
13 |
13 |
$65.00 |