| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,097 |
1,089 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,353 |
1,347 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
1,052 |
1,046 |
$78K |
| D1120 |
Prophylaxis - child |
1,127 |
1,123 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,913 |
1,843 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,339 |
2,328 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
668 |
662 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,212 |
1,208 |
$26K |
| D0350 |
|
1,402 |
621 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
85 |
38 |
$6K |
| D1351 |
Sealant - per tooth |
149 |
26 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
14 |
$3K |
| D9430 |
|
69 |
66 |
$2K |
| D4910 |
|
12 |
12 |
$924.00 |
| D0272 |
Bitewings - two radiographic images |
74 |
74 |
$888.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |