| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,059 |
1,052 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,015 |
1,013 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,067 |
1,061 |
$58K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,136 |
3,334 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,506 |
1,498 |
$32K |
| D0350 |
|
1,418 |
867 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
223 |
66 |
$12K |
| D1120 |
Prophylaxis - child |
323 |
321 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
493 |
491 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
93 |
44 |
$6K |
| D2140 |
|
73 |
37 |
$4K |
| D1320 |
|
129 |
129 |
$2K |
| D2160 |
|
21 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D9430 |
|
30 |
28 |
$928.00 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$360.00 |