| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
598 |
597 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
984 |
980 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,165 |
2,110 |
$42K |
| D1120 |
Prophylaxis - child |
1,125 |
1,121 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
472 |
472 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,061 |
2,056 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,983 |
1,979 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
76 |
39 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
127 |
55 |
$9K |
| D1351 |
Sealant - per tooth |
266 |
57 |
$6K |
| D0350 |
|
19 |
14 |
$220.80 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |