| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
888 |
887 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
921 |
918 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,538 |
1,517 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
616 |
616 |
$24K |
| D4341 |
|
362 |
116 |
$24K |
| D0274 |
Bitewings - four radiographic images |
774 |
774 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
218 |
121 |
$15K |
| D2140 |
|
235 |
111 |
$12K |
| D1120 |
Prophylaxis - child |
415 |
414 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
177 |
80 |
$9K |
| D5110 |
|
13 |
13 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
693 |
693 |
$6K |
| D2330 |
|
64 |
28 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
37 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
327 |
321 |
$4K |
| D0272 |
Bitewings - two radiographic images |
146 |
146 |
$2K |
| D4342 |
|
30 |
12 |
$1K |
| D9430 |
|
25 |
25 |
$700.00 |