| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
333 |
333 |
$15K |
| D1120 |
Prophylaxis - child |
444 |
443 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
404 |
403 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
163 |
76 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
232 |
232 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,691 |
530 |
$10K |
| D4341 |
|
176 |
48 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
538 |
531 |
$5K |
| D0274 |
Bitewings - four radiographic images |
266 |
266 |
$5K |
| D9430 |
|
131 |
126 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
28 |
$3K |
| D4910 |
|
28 |
28 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
186 |
181 |
$2K |
| D0350 |
|
188 |
95 |
$2K |
| D1351 |
Sealant - per tooth |
68 |
16 |
$1K |
| D0272 |
Bitewings - two radiographic images |
80 |
80 |
$838.00 |