| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2140 |
|
954 |
415 |
$51K |
| D0350 |
|
2,960 |
1,207 |
$28K |
| D4910 |
|
301 |
301 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,996 |
1,345 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
303 |
302 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
243 |
243 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
715 |
707 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
179 |
179 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
83 |
51 |
$6K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$4K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$2K |
| D0272 |
Bitewings - two radiographic images |
185 |
182 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
14 |
$1K |
| D9430 |
|
41 |
39 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
31 |
$360.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$198.00 |