| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,970 |
2,953 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,528 |
2,517 |
$78K |
| D1351 |
Sealant - per tooth |
1,279 |
288 |
$44K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
860 |
456 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
638 |
414 |
$24K |
| D9999 |
Unspecified adjunctive procedure, by report |
134 |
134 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
437 |
435 |
$16K |
| D2140 |
|
392 |
243 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,627 |
833 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
287 |
287 |
$7K |
| D0274 |
Bitewings - four radiographic images |
659 |
654 |
$6K |
| D0999 |
Unspecified diagnostic procedure, by report |
45 |
45 |
$3K |
| D0272 |
Bitewings - two radiographic images |
258 |
258 |
$2K |
| D1999 |
|
327 |
325 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$560.00 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$325.00 |
| D9430 |
|
13 |
13 |
$192.00 |
| D1330 |
|
12 |
12 |
$0.00 |