| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,177 |
2,172 |
$115K |
| D1120 |
Prophylaxis - child |
2,501 |
2,491 |
$96K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
642 |
350 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,291 |
1,285 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
471 |
245 |
$25K |
| D1206 |
Topical application of fluoride varnish |
2,201 |
2,194 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,020 |
2,525 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
386 |
386 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
326 |
179 |
$21K |
| D2140 |
|
373 |
213 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,029 |
970 |
$12K |
| D1110 |
Prophylaxis - adult |
120 |
119 |
$10K |
| D9430 |
|
235 |
232 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
303 |
301 |
$4K |
| D1351 |
Sealant - per tooth |
121 |
52 |
$3K |
| D2330 |
|
27 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$485.00 |
| D1999 |
|
24 |
24 |
$0.00 |
| D1330 |
|
26 |
26 |
$0.00 |