| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,262 |
6,259 |
$202K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,945 |
1,434 |
$153K |
| D0120 |
Periodic oral evaluation - established patient |
5,706 |
5,706 |
$107K |
| D0274 |
Bitewings - four radiographic images |
4,354 |
4,354 |
$78K |
| D0210 |
Intraoral - complete series of radiographic images |
3,660 |
3,641 |
$74K |
| D2750 |
|
147 |
92 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
6,506 |
6,482 |
$59K |
| D2140 |
|
1,201 |
932 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,428 |
2,426 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,730 |
5,638 |
$48K |
| D1120 |
Prophylaxis - child |
952 |
952 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,767 |
1,767 |
$20K |
| D1351 |
Sealant - per tooth |
307 |
76 |
$11K |
| D0272 |
Bitewings - two radiographic images |
408 |
408 |
$5K |
| D2954 |
|
33 |
27 |
$3K |
| D3320 |
|
14 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
67 |
40 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
254 |
247 |
$2K |
| D2331 |
|
17 |
12 |
$592.87 |
| D0270 |
|
14 |
14 |
$135.64 |