| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,631 |
1,623 |
$102K |
| D0210 |
Intraoral - complete series of radiographic images |
1,178 |
1,174 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
943 |
941 |
$52K |
| D1110 |
Prophylaxis - adult |
495 |
495 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,284 |
1,818 |
$37K |
| D1120 |
Prophylaxis - child |
804 |
800 |
$27K |
| D2740 |
Crown - porcelain/ceramic |
39 |
19 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,034 |
1,033 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
104 |
45 |
$11K |
| D0272 |
Bitewings - two radiographic images |
517 |
512 |
$6K |
| D1351 |
Sealant - per tooth |
227 |
51 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
308 |
308 |
$4K |
| D0274 |
Bitewings - four radiographic images |
153 |
153 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
28 |
12 |
$2K |
| D9430 |
|
13 |
13 |
$416.00 |