| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,215 |
3,213 |
$180K |
| D1120 |
Prophylaxis - child |
3,955 |
3,953 |
$152K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25,723 |
4,573 |
$105K |
| D1351 |
Sealant - per tooth |
3,375 |
1,066 |
$91K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,381 |
801 |
$91K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,085 |
1,085 |
$69K |
| D2140 |
|
1,016 |
614 |
$54K |
| D0272 |
Bitewings - two radiographic images |
4,168 |
4,165 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,956 |
3,954 |
$43K |
| D0350 |
|
4,440 |
1,293 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
41 |
$6K |
| D2160 |
|
40 |
25 |
$3K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
19 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$1K |