| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,091 |
957 |
$34K |
| D1999 |
|
2,269 |
1,867 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
867 |
733 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
341 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,044 |
844 |
$9K |
| D0272 |
Bitewings - two radiographic images |
491 |
465 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
845 |
759 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
326 |
260 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
369 |
317 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
39 |
29 |
$3K |
| D1120 |
Prophylaxis - child |
161 |
143 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
46 |
41 |
$2K |
| D2140 |
|
20 |
14 |
$785.40 |