| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,345 |
4,200 |
$73K |
| D1110 |
Prophylaxis - adult |
1,742 |
1,685 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,635 |
3,533 |
$54K |
| D1120 |
Prophylaxis - child |
2,580 |
2,492 |
$50K |
| D0330 |
Panoramic radiographic image |
975 |
938 |
$44K |
| D0272 |
Bitewings - two radiographic images |
3,643 |
3,537 |
$28K |
| D1351 |
Sealant - per tooth |
890 |
260 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
234 |
169 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
172 |
124 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
12 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
12 |
$850.50 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
25 |
$103.00 |
| D1330 |
|
3,065 |
2,956 |
$0.00 |