| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,482 |
2,481 |
$164K |
| D0120 |
Periodic oral evaluation - established patient |
1,534 |
1,532 |
$122K |
| D1110 |
Prophylaxis - adult |
1,262 |
1,262 |
$112K |
| D1351 |
Sealant - per tooth |
2,845 |
610 |
$108K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,446 |
4,002 |
$91K |
| D1120 |
Prophylaxis - child |
1,759 |
1,757 |
$91K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,212 |
589 |
$81K |
| D0350 |
|
6,860 |
1,849 |
$66K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
543 |
390 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,040 |
3,038 |
$45K |
| D0274 |
Bitewings - four radiographic images |
2,070 |
2,069 |
$45K |
| D2140 |
|
809 |
395 |
$44K |
| D4341 |
|
332 |
99 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,584 |
1,583 |
$19K |
| D0330 |
Panoramic radiographic image |
546 |
544 |
$16K |
| D2160 |
|
113 |
78 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
27 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
92 |
$1K |