| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
675 |
665 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
453 |
446 |
$21K |
| D1110 |
Prophylaxis - adult |
209 |
209 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
532 |
528 |
$7K |
| D1120 |
Prophylaxis - child |
190 |
188 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
750 |
154 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
12 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
38 |
38 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
25 |
13 |
$2K |
| D1320 |
|
153 |
152 |
$2K |
| D1351 |
Sealant - per tooth |
58 |
17 |
$1K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$518.40 |