| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,145 |
1,137 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,165 |
1,157 |
$23K |
| D0274 |
Bitewings - four radiographic images |
445 |
442 |
$12K |
| D1120 |
Prophylaxis - child |
220 |
219 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
28 |
$3K |
| D1206 |
Topical application of fluoride varnish |
159 |
158 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
19 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
15 |
$1K |
| D1351 |
Sealant - per tooth |
47 |
12 |
$860.00 |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
76 |
$659.60 |