| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,303 |
5,278 |
$320K |
| D1110 |
Prophylaxis - adult |
2,504 |
2,494 |
$220K |
| D1120 |
Prophylaxis - child |
3,961 |
3,944 |
$158K |
| D0230 |
Intraoral - periapical each additional radiographic image |
35,143 |
6,588 |
$141K |
| D0274 |
Bitewings - four radiographic images |
5,137 |
5,119 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,607 |
1,606 |
$105K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,429 |
6,406 |
$82K |
| D1351 |
Sealant - per tooth |
2,918 |
555 |
$82K |
| D7140 |
Extraction, erupted tooth or exposed root |
955 |
606 |
$55K |
| D0330 |
Panoramic radiographic image |
1,093 |
1,091 |
$33K |
| D0350 |
|
1,799 |
1,027 |
$17K |
| D9110 |
|
141 |
139 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
25 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
34 |
26 |
$2K |
| D9430 |
|
39 |
38 |
$1K |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$456.00 |