| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,082 |
2,082 |
$134K |
| D1110 |
Prophylaxis - adult |
1,225 |
1,224 |
$108K |
| D0210 |
Intraoral - complete series of radiographic images |
1,821 |
1,820 |
$86K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
943 |
555 |
$63K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
340 |
144 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,325 |
2,324 |
$30K |
| D2140 |
|
507 |
251 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
490 |
490 |
$24K |
| D1120 |
Prophylaxis - child |
747 |
747 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
294 |
137 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,802 |
712 |
$16K |
| D0350 |
|
1,222 |
544 |
$12K |
| D0330 |
Panoramic radiographic image |
393 |
393 |
$12K |
| D0274 |
Bitewings - four radiographic images |
387 |
387 |
$8K |
| D1351 |
Sealant - per tooth |
367 |
107 |
$8K |
| D2330 |
|
97 |
60 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
60 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
71 |
25 |
$4K |
| D2160 |
|
40 |
25 |
$3K |