| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
972 |
971 |
$56K |
| D0274 |
Bitewings - four radiographic images |
992 |
992 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,409 |
1,251 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,139 |
1,139 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,144 |
1,144 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
336 |
110 |
$28K |
| D0330 |
Panoramic radiographic image |
361 |
361 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,320 |
1,305 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
510 |
510 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
424 |
417 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
116 |
$15K |
| D1120 |
Prophylaxis - child |
352 |
352 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
141 |
69 |
$11K |
| D4341 |
|
36 |
13 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
33 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
18 |
$1K |
| D4910 |
|
13 |
12 |
$1K |
| D1330 |
|
30 |
30 |
$795.71 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$369.54 |
| D9985 |
|
24 |
24 |
$0.00 |