| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
648 |
565 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
248 |
113 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
450 |
398 |
$11K |
| D0274 |
Bitewings - four radiographic images |
506 |
430 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
73 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
464 |
408 |
$7K |
| D2140 |
|
135 |
76 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
41 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
92 |
46 |
$5K |
| D1206 |
Topical application of fluoride varnish |
313 |
276 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
185 |
174 |
$4K |
| D1120 |
Prophylaxis - child |
161 |
144 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
401 |
338 |
$2K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$694.80 |
| D0272 |
Bitewings - two radiographic images |
20 |
19 |
$180.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
28 |
$170.00 |