| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
449 |
445 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
429 |
425 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
448 |
444 |
$11K |
| D1351 |
Sealant - per tooth |
169 |
98 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
103 |
82 |
$7K |
| D0274 |
Bitewings - four radiographic images |
167 |
166 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
118 |
$2K |
| D0272 |
Bitewings - two radiographic images |
244 |
241 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
221 |
$1K |
| D9110 |
|
16 |
16 |
$880.00 |
| D2140 |
|
20 |
17 |
$740.40 |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
14 |
$704.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
141 |
139 |
$691.60 |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$591.80 |