| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,642 |
1,640 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
679 |
678 |
$39K |
| D1110 |
Prophylaxis - adult |
475 |
471 |
$39K |
| D1120 |
Prophylaxis - child |
1,305 |
1,301 |
$38K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
536 |
278 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,846 |
1,863 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
581 |
580 |
$26K |
| D4910 |
|
317 |
316 |
$24K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
43 |
34 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,372 |
1,364 |
$15K |
| D0274 |
Bitewings - four radiographic images |
710 |
710 |
$15K |
| D2140 |
|
273 |
109 |
$14K |
| D0330 |
Panoramic radiographic image |
408 |
405 |
$11K |
| D4341 |
|
161 |
52 |
$8K |
| D0272 |
Bitewings - two radiographic images |
685 |
682 |
$8K |
| D0350 |
|
765 |
329 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
500 |
500 |
$5K |
| D9430 |
|
126 |
124 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
243 |
$3K |
| D2954 |
|
17 |
14 |
$2K |
| D2160 |
|
20 |
13 |
$2K |
| D9993 |
|
13 |
13 |
$845.00 |
| D1310 |
|
13 |
13 |
$598.00 |