| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
928 |
897 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
383 |
181 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
888 |
854 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
124 |
86 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
258 |
243 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
282 |
266 |
$9K |
| D0274 |
Bitewings - four radiographic images |
282 |
266 |
$8K |
| D1120 |
Prophylaxis - child |
226 |
206 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
369 |
329 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
67 |
$1K |
| D0272 |
Bitewings - two radiographic images |
54 |
45 |
$783.71 |