| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
859 |
857 |
$49K |
| D1110 |
Prophylaxis - adult |
524 |
522 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
835 |
825 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
600 |
598 |
$27K |
| D1120 |
Prophylaxis - child |
798 |
789 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,156 |
1,022 |
$20K |
| D1206 |
Topical application of fluoride varnish |
775 |
766 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
547 |
544 |
$7K |
| D0272 |
Bitewings - two radiographic images |
367 |
364 |
$4K |
| D4910 |
|
43 |
43 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
343 |
320 |
$3K |
| D4341 |
|
48 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
112 |
26 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
18 |
12 |
$1K |