| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1999 |
|
1,932 |
1,304 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
353 |
77 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,171 |
799 |
$17K |
| D1120 |
Prophylaxis - child |
850 |
550 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
599 |
378 |
$9K |
| D1351 |
Sealant - per tooth |
349 |
33 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
167 |
118 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
48 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
79 |
39 |
$1K |
| D1110 |
Prophylaxis - adult |
24 |
12 |
$668.40 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$370.32 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$228.58 |
| D9995 |
|
13 |
13 |
$182.00 |