| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,659 |
1,656 |
$83K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
880 |
405 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
977 |
975 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
1,056 |
1,054 |
$48K |
| D1120 |
Prophylaxis - child |
1,295 |
1,290 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,926 |
1,980 |
$39K |
| D1110 |
Prophylaxis - adult |
416 |
413 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,227 |
2,221 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,049 |
1,048 |
$21K |
| D0330 |
Panoramic radiographic image |
742 |
742 |
$21K |
| D2160 |
|
115 |
73 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
133 |
55 |
$7K |
| D1351 |
Sealant - per tooth |
282 |
75 |
$6K |
| D2140 |
|
39 |
24 |
$2K |
| D4341 |
|
37 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
158 |
150 |
$2K |
| D9430 |
|
15 |
14 |
$480.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$288.00 |