| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,055 |
2,050 |
$177K |
| D0120 |
Periodic oral evaluation - established patient |
2,928 |
2,917 |
$166K |
| D4341 |
|
1,548 |
422 |
$108K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,904 |
4,274 |
$96K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,535 |
796 |
$86K |
| D1120 |
Prophylaxis - child |
2,088 |
2,081 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,059 |
1,059 |
$67K |
| D0274 |
Bitewings - four radiographic images |
2,943 |
2,932 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,218 |
4,204 |
$54K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
293 |
128 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,150 |
1,085 |
$13K |
| D1351 |
Sealant - per tooth |
489 |
113 |
$12K |
| D4910 |
|
146 |
146 |
$11K |
| D2160 |
|
70 |
36 |
$6K |
| D0272 |
Bitewings - two radiographic images |
392 |
391 |
$5K |
| D9993 |
|
12 |
12 |
$715.00 |
| D1310 |
|
12 |
12 |
$506.00 |
| D9430 |
|
14 |
14 |
$448.00 |
| D1999 |
|
43 |
42 |
$0.00 |