| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
575 |
575 |
$40K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
641 |
303 |
$29K |
| D1120 |
Prophylaxis - child |
527 |
523 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,604 |
1,600 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
81 |
43 |
$6K |
| D1351 |
Sealant - per tooth |
483 |
156 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,444 |
1,440 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
144 |
140 |
$4K |
| D2140 |
|
125 |
92 |
$4K |
| D0274 |
Bitewings - four radiographic images |
169 |
169 |
$2K |
| D4910 |
|
26 |
26 |
$1K |
| D0272 |
Bitewings - two radiographic images |
125 |
124 |
$980.04 |
| D2160 |
|
16 |
14 |
$914.72 |
| D0220 |
Intraoral - periapical first radiographic image |
192 |
175 |
$910.14 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$470.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$220.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
12 |
$127.40 |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$14.84 |
| D1999 |
|
18 |
18 |
$0.00 |