| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,080 |
3,073 |
$239K |
| D1120 |
Prophylaxis - child |
3,164 |
3,157 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
2,095 |
2,076 |
$55K |
| D1351 |
Sealant - per tooth |
2,574 |
548 |
$51K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
623 |
379 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
329 |
328 |
$32K |
| D2140 |
|
514 |
367 |
$28K |
| D1206 |
Topical application of fluoride varnish |
3,458 |
3,450 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,219 |
1,214 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,002 |
1,874 |
$6K |
| D0274 |
Bitewings - four radiographic images |
658 |
655 |
$4K |
| D0330 |
Panoramic radiographic image |
413 |
413 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
26 |
$3K |
| D1110 |
Prophylaxis - adult |
176 |
176 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$418.89 |