| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
212 |
200 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
212 |
200 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
173 |
163 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
76 |
41 |
$5K |
| D9110 |
|
71 |
68 |
$4K |
| D2140 |
|
79 |
48 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
122 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
33 |
$2K |
| D1110 |
Prophylaxis - adult |
50 |
47 |
$2K |
| D0274 |
Bitewings - four radiographic images |
115 |
107 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
331 |
308 |
$2K |
| D1351 |
Sealant - per tooth |
27 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
263 |
190 |
$1K |
| D0272 |
Bitewings - two radiographic images |
83 |
78 |
$761.40 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$194.40 |