| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9110 |
|
505 |
450 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
585 |
584 |
$22K |
| D1120 |
Prophylaxis - child |
611 |
611 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,793 |
1,107 |
$13K |
| D1351 |
Sealant - per tooth |
488 |
155 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
571 |
500 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
678 |
678 |
$6K |
| D0274 |
Bitewings - four radiographic images |
279 |
279 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
28 |
$3K |
| D0272 |
Bitewings - two radiographic images |
232 |
232 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
12 |
$1K |
| D0350 |
|
63 |
39 |
$465.60 |
| D9430 |
|
15 |
15 |
$420.00 |