| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
855 |
850 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,017 |
1,011 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
597 |
593 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
469 |
469 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
299 |
143 |
$16K |
| D1120 |
Prophylaxis - child |
440 |
439 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,904 |
615 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
77 |
46 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
802 |
800 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
107 |
70 |
$7K |
| D0274 |
Bitewings - four radiographic images |
362 |
353 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
391 |
370 |
$4K |
| D2330 |
|
42 |
24 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
28 |
$3K |
| D2140 |
|
34 |
25 |
$2K |
| D2160 |
|
19 |
14 |
$1K |
| D9110 |
|
16 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$260.00 |