| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,432 |
1,430 |
$163K |
| D1351 |
Sealant - per tooth |
1,136 |
182 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
729 |
726 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
211 |
100 |
$11K |
| D1120 |
Prophylaxis - child |
1,393 |
1,391 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$5K |
| D1206 |
Topical application of fluoride varnish |
1,512 |
1,510 |
$5K |
| D0272 |
Bitewings - two radiographic images |
675 |
673 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,181 |
558 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
377 |
377 |
$613.30 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$589.46 |
| D2140 |
|
30 |
16 |
$378.75 |
| D0330 |
Panoramic radiographic image |
125 |
125 |
$168.09 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$0.00 |