| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,550 |
2,540 |
$215K |
| D0120 |
Periodic oral evaluation - established patient |
2,237 |
2,227 |
$115K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,445 |
2,738 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
976 |
975 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,360 |
2,350 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,505 |
1,500 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
505 |
246 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
425 |
425 |
$20K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
159 |
106 |
$19K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
200 |
157 |
$13K |
| D4910 |
|
162 |
162 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,034 |
1,024 |
$12K |
| D4341 |
|
153 |
40 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
22 |
16 |
$10K |
| D0330 |
Panoramic radiographic image |
277 |
277 |
$8K |
| D0350 |
|
743 |
470 |
$7K |
| D2954 |
|
21 |
12 |
$2K |
| D9430 |
|
63 |
63 |
$2K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$434.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |