| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,513 |
1,513 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,711 |
1,711 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,361 |
1,360 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,668 |
1,649 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
301 |
155 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
723 |
723 |
$17K |
| D1351 |
Sealant - per tooth |
446 |
102 |
$16K |
| D1120 |
Prophylaxis - child |
342 |
341 |
$12K |
| D0330 |
Panoramic radiographic image |
490 |
490 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
157 |
92 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
605 |
604 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
81 |
38 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
60 |
$5K |
| D2335 |
|
19 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
13 |
$2K |
| D2140 |
|
28 |
13 |
$1K |
| D2330 |
|
22 |
12 |
$933.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
86 |
$908.35 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$310.40 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$242.25 |
| D1999 |
|
101 |
99 |
$0.00 |