| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,537 |
1,533 |
$81K |
| D0210 |
Intraoral - complete series of radiographic images |
695 |
692 |
$32K |
| D1110 |
Prophylaxis - adult |
370 |
368 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
515 |
514 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,875 |
1,226 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
336 |
210 |
$22K |
| D1120 |
Prophylaxis - child |
615 |
615 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,056 |
1,056 |
$12K |
| D4341 |
|
110 |
51 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
496 |
496 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
31 |
$4K |
| D2160 |
|
16 |
13 |
$1K |
| D4910 |
|
13 |
13 |
$1K |
| D2140 |
|
13 |
12 |
$709.80 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$130.00 |