| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,073 |
1,071 |
$135K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
435 |
435 |
$57K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
723 |
393 |
$53K |
| D2160 |
|
810 |
357 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
711 |
671 |
$31K |
| D0330 |
Panoramic radiographic image |
328 |
327 |
$18K |
| D1351 |
Sealant - per tooth |
760 |
163 |
$15K |
| D0272 |
Bitewings - two radiographic images |
640 |
636 |
$9K |
| D7240 |
Removal of impacted tooth - completely bony |
40 |
13 |
$8K |
| D2140 |
|
289 |
145 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
87 |
$6K |
| D2161 |
|
88 |
43 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
185 |
107 |
$3K |
| D0274 |
Bitewings - four radiographic images |
624 |
623 |
$2K |
| D1110 |
Prophylaxis - adult |
263 |
263 |
$2K |
| D2335 |
|
27 |
14 |
$2K |
| D1120 |
Prophylaxis - child |
891 |
886 |
$2K |
| D1206 |
Topical application of fluoride varnish |
926 |
925 |
$1K |