| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
644 |
643 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
910 |
910 |
$48K |
| D1120 |
Prophylaxis - child |
1,227 |
1,227 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,347 |
2,341 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,981 |
2,070 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,294 |
1,291 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
106 |
$7K |
| D4910 |
|
81 |
81 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
454 |
446 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
25 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
12 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
13 |
$1K |
| D9430 |
|
36 |
36 |
$1K |
| D1351 |
Sealant - per tooth |
44 |
13 |
$946.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$420.00 |