| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,636 |
3,634 |
$199K |
| D1120 |
Prophylaxis - child |
3,243 |
3,239 |
$123K |
| D1110 |
Prophylaxis - adult |
1,446 |
1,446 |
$122K |
| D1351 |
Sealant - per tooth |
3,264 |
856 |
$89K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,623 |
4,593 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,209 |
1,208 |
$76K |
| D0272 |
Bitewings - two radiographic images |
4,447 |
4,446 |
$53K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
470 |
228 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,276 |
2,273 |
$30K |
| D2140 |
|
550 |
284 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
416 |
180 |
$24K |
| D9993 |
|
117 |
117 |
$7K |
| D1310 |
|
131 |
131 |
$6K |
| D0601 |
|
126 |
126 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
154 |
$2K |
| D4910 |
|
13 |
13 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
15 |
$525.00 |