| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,528 |
3,611 |
$116K |
| D0330 |
Panoramic radiographic image |
2,200 |
1,831 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
4,616 |
3,610 |
$58K |
| D0272 |
Bitewings - two radiographic images |
3,230 |
2,620 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,204 |
1,669 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,551 |
1,243 |
$24K |
| D2140 |
|
832 |
463 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
708 |
424 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
658 |
406 |
$18K |
| D1120 |
Prophylaxis - child |
1,020 |
799 |
$17K |
| D1351 |
Sealant - per tooth |
669 |
63 |
$9K |
| D1999 |
|
236 |
213 |
$4K |
| D2940 |
|
117 |
64 |
$2K |
| D2330 |
|
66 |
24 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
110 |
86 |
$1K |
| D2335 |
|
23 |
15 |
$763.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
195 |
139 |
$624.31 |