| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,015 |
3,977 |
$483K |
| D1351 |
Sealant - per tooth |
4,555 |
773 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
708 |
683 |
$94K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,859 |
854 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
2,859 |
2,791 |
$26K |
| D1120 |
Prophylaxis - child |
4,364 |
4,306 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
284 |
277 |
$14K |
| D2140 |
|
508 |
327 |
$14K |
| D1206 |
Topical application of fluoride varnish |
4,836 |
4,764 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
48 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,783 |
2,577 |
$4K |
| D0330 |
Panoramic radiographic image |
142 |
139 |
$4K |
| D0272 |
Bitewings - two radiographic images |
3,133 |
3,089 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
40 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,447 |
1,419 |
$1K |
| D2160 |
|
13 |
12 |
$438.77 |
| D1110 |
Prophylaxis - adult |
243 |
241 |
$362.61 |