| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,829 |
1,827 |
$146K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
909 |
389 |
$104K |
| D9430 |
|
3,066 |
2,472 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
1,818 |
1,810 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,441 |
1,441 |
$86K |
| D0210 |
Intraoral - complete series of radiographic images |
1,322 |
1,322 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,859 |
1,905 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,749 |
2,742 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,261 |
1,255 |
$25K |
| D1120 |
Prophylaxis - child |
404 |
404 |
$13K |
| D4341 |
|
142 |
42 |
$10K |
| D5750 |
|
34 |
34 |
$6K |
| D5751 |
|
15 |
15 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
42 |
$415.00 |
| D1999 |
|
31 |
29 |
$45.00 |
| D9995 |
|
14 |
14 |
$0.72 |