| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,063 |
1,049 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
1,262 |
1,256 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
900 |
900 |
$55K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
817 |
345 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,701 |
1,866 |
$37K |
| D1120 |
Prophylaxis - child |
971 |
965 |
$34K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
291 |
137 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
639 |
639 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,300 |
2,294 |
$27K |
| D2140 |
|
451 |
168 |
$25K |
| D0350 |
|
1,982 |
915 |
$19K |
| D0274 |
Bitewings - four radiographic images |
741 |
739 |
$15K |
| D2160 |
|
86 |
50 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
345 |
335 |
$4K |
| D1351 |
Sealant - per tooth |
148 |
39 |
$4K |
| D9430 |
|
92 |
92 |
$3K |
| D1320 |
|
158 |
158 |
$3K |