| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,872 |
4,856 |
$422K |
| D1120 |
Prophylaxis - child |
4,522 |
4,510 |
$49K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
554 |
357 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
400 |
399 |
$35K |
| D0272 |
Bitewings - two radiographic images |
3,885 |
3,871 |
$28K |
| D1206 |
Topical application of fluoride varnish |
4,726 |
4,722 |
$27K |
| D1351 |
Sealant - per tooth |
509 |
96 |
$12K |
| D2140 |
|
179 |
127 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
66 |
$8K |
| D0274 |
Bitewings - four radiographic images |
557 |
555 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
95 |
64 |
$7K |
| D0330 |
Panoramic radiographic image |
348 |
347 |
$4K |
| D1110 |
Prophylaxis - adult |
266 |
264 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
172 |
$889.45 |
| D1208 |
Topical application of fluoride, excluding varnish |
603 |
593 |
$333.00 |