| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,765 |
1,765 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
2,095 |
2,095 |
$48K |
| D0272 |
Bitewings - two radiographic images |
1,400 |
1,400 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
981 |
981 |
$16K |
| D1120 |
Prophylaxis - child |
277 |
277 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
234 |
234 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
73 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
207 |
$2K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
14 |
12 |
$1K |