| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,584 |
1,555 |
$120K |
| D1120 |
Prophylaxis - child |
2,129 |
2,102 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,460 |
1,453 |
$96K |
| D1110 |
Prophylaxis - adult |
744 |
738 |
$66K |
| D0210 |
Intraoral - complete series of radiographic images |
1,034 |
1,023 |
$49K |
| D1351 |
Sealant - per tooth |
997 |
201 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,518 |
1,499 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,970 |
1,945 |
$28K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
207 |
163 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
829 |
784 |
$10K |
| D9430 |
|
287 |
281 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,660 |
827 |
$7K |
| D2140 |
|
91 |
71 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$2K |
| D4341 |
|
30 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
88 |
88 |
$1K |
| D1310 |
|
12 |
12 |
$552.00 |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$234.00 |
| D9993 |
|
12 |
12 |
$0.00 |