| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,273 |
3,258 |
$174K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,582 |
820 |
$105K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25,150 |
4,529 |
$102K |
| D1110 |
Prophylaxis - adult |
1,184 |
1,178 |
$98K |
| D1120 |
Prophylaxis - child |
2,379 |
2,363 |
$87K |
| D0274 |
Bitewings - four radiographic images |
3,590 |
3,571 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
598 |
594 |
$36K |
| D2160 |
|
349 |
214 |
$28K |
| D4341 |
|
163 |
46 |
$10K |
| D7240 |
Removal of impacted tooth - completely bony |
26 |
12 |
$6K |
| D9430 |
|
119 |
112 |
$4K |
| D2140 |
|
45 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
183 |
170 |
$2K |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$928.00 |
| D1351 |
Sealant - per tooth |
37 |
12 |
$814.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$480.00 |