| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,972 |
1,949 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,866 |
2,834 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
549 |
301 |
$39K |
| D1120 |
Prophylaxis - child |
791 |
784 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
825 |
813 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,206 |
1,191 |
$30K |
| D0274 |
Bitewings - four radiographic images |
705 |
697 |
$24K |
| D0330 |
Panoramic radiographic image |
309 |
305 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
768 |
730 |
$11K |
| D0272 |
Bitewings - two radiographic images |
280 |
276 |
$8K |
| D5650 |
|
66 |
39 |
$5K |
| D5422 |
|
114 |
114 |
$5K |
| D2140 |
|
48 |
26 |
$3K |
| D5421 |
|
30 |
30 |
$2K |
| D1351 |
Sealant - per tooth |
47 |
12 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
12 |
$1K |
| D5411 |
|
26 |
26 |
$1K |
| D5410 |
|
13 |
13 |
$608.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$148.00 |