| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
434 |
427 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
129 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
166 |
165 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
94 |
50 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
576 |
559 |
$4K |
| D2140 |
|
48 |
29 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
417 |
412 |
$981.71 |
| D1120 |
Prophylaxis - child |
382 |
378 |
$817.09 |
| D0330 |
Panoramic radiographic image |
57 |
55 |
$519.39 |
| D0272 |
Bitewings - two radiographic images |
134 |
134 |
$294.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
503 |
446 |
$243.71 |
| D0274 |
Bitewings - four radiographic images |
234 |
231 |
$141.29 |
| D1110 |
Prophylaxis - adult |
60 |
59 |
$121.09 |