| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
493 |
262 |
$192K |
| D1110 |
Prophylaxis - adult |
2,747 |
2,746 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
6,178 |
6,173 |
$49K |
| D2954 |
|
377 |
239 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
2,099 |
1,948 |
$32K |
| D1120 |
Prophylaxis - child |
2,487 |
2,486 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,394 |
2,326 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
2,681 |
2,618 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,838 |
3,835 |
$10K |
| D0274 |
Bitewings - four radiographic images |
736 |
736 |
$6K |
| D4341 |
|
36 |
13 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
73 |
71 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
12 |
$879.10 |
| D0272 |
Bitewings - two radiographic images |
201 |
201 |
$450.44 |
| D1351 |
Sealant - per tooth |
16 |
16 |
$412.80 |
| D1999 |
|
102 |
86 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
19 |
$0.00 |