| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,922 |
1,919 |
$164K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
397 |
395 |
$38K |
| D1120 |
Prophylaxis - child |
2,222 |
2,218 |
$31K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
329 |
140 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,515 |
1,511 |
$18K |
| D1206 |
Topical application of fluoride varnish |
2,101 |
2,100 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
401 |
396 |
$10K |
| D2140 |
|
71 |
28 |
$7K |
| D1351 |
Sealant - per tooth |
67 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
299 |
299 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
24 |
$1K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
132 |
123 |
$827.55 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$408.20 |
| D9248 |
|
12 |
12 |
$192.71 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |