| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,243 |
1,243 |
$43K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
664 |
353 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,576 |
1,575 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,696 |
1,695 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,026 |
1,026 |
$22K |
| D1120 |
Prophylaxis - child |
557 |
557 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
427 |
389 |
$4K |
| D2140 |
|
75 |
55 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
115 |
35 |
$3K |
| D0191 |
|
107 |
107 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$2K |
| D2160 |
|
33 |
29 |
$1K |
| D4910 |
|
28 |
28 |
$910.00 |
| D0140 |
Limited oral evaluation - problem focused |
54 |
53 |
$776.75 |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$728.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
146 |
76 |
$657.00 |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$638.00 |
| D4355 |
|
12 |
12 |
$378.00 |
| D1354 |
|
394 |
191 |
$318.00 |
| D1999 |
|
24 |
24 |
$168.00 |
| D1330 |
|
582 |
578 |
$30.00 |