| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
712 |
709 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
849 |
838 |
$16K |
| D1351 |
Sealant - per tooth |
498 |
115 |
$12K |
| D0330 |
Panoramic radiographic image |
255 |
244 |
$9K |
| D0272 |
Bitewings - two radiographic images |
488 |
477 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
402 |
398 |
$7K |
| D1120 |
Prophylaxis - child |
188 |
188 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
251 |
246 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
13 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
145 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
13 |
12 |
$747.00 |
| D2140 |
|
17 |
14 |
$630.00 |