| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,371 |
4,370 |
$182K |
| D1120 |
Prophylaxis - child |
4,439 |
4,439 |
$133K |
| D0230 |
Intraoral - periapical each additional radiographic image |
29,084 |
5,409 |
$117K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,492 |
796 |
$100K |
| D1351 |
Sealant - per tooth |
3,380 |
827 |
$73K |
| D1110 |
Prophylaxis - adult |
875 |
875 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,097 |
1,096 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,409 |
5,404 |
$56K |
| D0272 |
Bitewings - two radiographic images |
4,445 |
4,443 |
$52K |
| D7140 |
Extraction, erupted tooth or exposed root |
498 |
319 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
611 |
608 |
$7K |
| D0350 |
|
470 |
229 |
$4K |
| D2140 |
|
60 |
40 |
$3K |
| D9430 |
|
92 |
92 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$1K |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$626.40 |