| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,416 |
2,414 |
$206K |
| D0120 |
Periodic oral evaluation - established patient |
2,611 |
2,606 |
$142K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,065 |
1,062 |
$66K |
| D0274 |
Bitewings - four radiographic images |
3,113 |
3,106 |
$66K |
| D1120 |
Prophylaxis - child |
1,158 |
1,155 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,739 |
4,338 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
647 |
414 |
$37K |
| D9430 |
|
676 |
670 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,701 |
1,657 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
71 |
56 |
$5K |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$604.00 |