| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,467 |
1,451 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
980 |
979 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,916 |
2,406 |
$40K |
| D1110 |
Prophylaxis - adult |
341 |
341 |
$26K |
| D1120 |
Prophylaxis - child |
748 |
744 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,490 |
1,484 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,630 |
1,604 |
$19K |
| D0330 |
Panoramic radiographic image |
436 |
434 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
222 |
222 |
$11K |
| D9430 |
|
324 |
291 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
29 |
16 |
$2K |
| D0274 |
Bitewings - four radiographic images |
113 |
113 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
23 |
15 |
$1K |
| D1351 |
Sealant - per tooth |
65 |
13 |
$1K |
| D4910 |
|
15 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$271.50 |
| D1330 |
|
13 |
13 |
$0.00 |
| D1999 |
|
26 |
24 |
$0.00 |