| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
12,617 |
12,609 |
$567K |
| D0120 |
Periodic oral evaluation - established patient |
16,630 |
16,614 |
$371K |
| D0220 |
Intraoral - periapical first radiographic image |
10,895 |
10,850 |
$116K |
| D0274 |
Bitewings - four radiographic images |
3,318 |
3,315 |
$73K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,161 |
7,134 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
1,156 |
1,154 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
240 |
200 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
144 |
108 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
559 |
557 |
$7K |
| D1120 |
Prophylaxis - child |
153 |
153 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
400 |
400 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
28 |
26 |
$2K |
| D4341 |
|
18 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
12 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$508.16 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$184.00 |