| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,847 |
3,835 |
$215K |
| D1120 |
Prophylaxis - child |
4,451 |
4,437 |
$173K |
| D1351 |
Sealant - per tooth |
3,817 |
1,259 |
$109K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,595 |
4,582 |
$58K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,336 |
3,313 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
674 |
387 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,524 |
1,519 |
$32K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
287 |
172 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,240 |
1,240 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
159 |
$10K |
| D2160 |
|
105 |
66 |
$8K |
| D2140 |
|
20 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |
| D1999 |
|
191 |
191 |
$0.00 |