| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
717 |
702 |
$42K |
| D1110 |
Prophylaxis - adult |
391 |
379 |
$29K |
| D1120 |
Prophylaxis - child |
477 |
461 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
991 |
960 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
251 |
245 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,673 |
741 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
152 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
56 |
31 |
$6K |
| D1351 |
Sealant - per tooth |
259 |
48 |
$5K |
| D9430 |
|
156 |
140 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
50 |
24 |
$3K |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
221 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
14 |
$2K |
| D2160 |
|
20 |
12 |
$2K |
| D9993 |
|
16 |
16 |
$975.00 |
| D1310 |
|
16 |
16 |
$690.00 |
| D0603 |
|
16 |
16 |
$225.00 |