| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
873 |
870 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
1,098 |
1,095 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
489 |
489 |
$31K |
| D2740 |
Crown - porcelain/ceramic |
55 |
33 |
$26K |
| D1120 |
Prophylaxis - child |
466 |
465 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,536 |
1,181 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
287 |
287 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,075 |
1,074 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
112 |
37 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
339 |
339 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
57 |
41 |
$4K |
| D2140 |
|
59 |
39 |
$3K |
| D1351 |
Sealant - per tooth |
70 |
27 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |