| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,332 |
2,324 |
$130K |
| D1110 |
Prophylaxis - adult |
1,354 |
1,349 |
$118K |
| D1120 |
Prophylaxis - child |
1,485 |
1,480 |
$57K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,175 |
2,376 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,996 |
2,987 |
$39K |
| D4910 |
|
510 |
506 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
535 |
535 |
$33K |
| D0272 |
Bitewings - two radiographic images |
2,182 |
2,174 |
$26K |
| D4341 |
|
276 |
78 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
219 |
219 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
19 |
12 |
$9K |
| D1351 |
Sealant - per tooth |
188 |
42 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
25 |
$3K |
| D2952 |
|
18 |
12 |
$2K |
| D0350 |
|
188 |
84 |
$355.20 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$312.50 |