| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,064 |
4,058 |
$215K |
| D1120 |
Prophylaxis - child |
4,508 |
4,503 |
$168K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26,715 |
4,990 |
$107K |
| D1351 |
Sealant - per tooth |
3,281 |
907 |
$91K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,264 |
670 |
$85K |
| D0274 |
Bitewings - four radiographic images |
2,898 |
2,895 |
$61K |
| D1206 |
Topical application of fluoride varnish |
4,933 |
4,927 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
979 |
978 |
$60K |
| D1110 |
Prophylaxis - adult |
304 |
303 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
248 |
154 |
$14K |
| D9430 |
|
448 |
434 |
$14K |
| D9993 |
|
208 |
208 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,112 |
1,089 |
$13K |
| D2140 |
|
204 |
136 |
$11K |
| D1310 |
|
208 |
208 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
192 |
191 |
$9K |
| D0350 |
|
924 |
472 |
$9K |
| D0272 |
Bitewings - two radiographic images |
719 |
719 |
$8K |
| D0330 |
Panoramic radiographic image |
230 |
230 |
$7K |
| D9248 |
|
112 |
108 |
$4K |
| D4341 |
|
46 |
12 |
$3K |
| D4910 |
|
12 |
12 |
$924.00 |
| D0603 |
|
39 |
39 |
$570.00 |
| D0602 |
|
24 |
24 |
$345.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$237.00 |