| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,351 |
2,337 |
$209K |
| D2140 |
|
817 |
274 |
$48K |
| D1120 |
Prophylaxis - child |
2,420 |
2,398 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
537 |
527 |
$29K |
| D1206 |
Topical application of fluoride varnish |
2,471 |
2,439 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,632 |
1,622 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
460 |
168 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
47 |
$13K |
| D1351 |
Sealant - per tooth |
268 |
57 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
79 |
36 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
14 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
287 |
223 |
$2K |
| D0274 |
Bitewings - four radiographic images |
363 |
357 |
$1K |
| D0330 |
Panoramic radiographic image |
182 |
182 |
$839.29 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$675.06 |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$161.48 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$0.00 |