| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,245 |
2,222 |
$172K |
| D1120 |
Prophylaxis - child |
2,998 |
2,971 |
$149K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,391 |
1,383 |
$93K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,761 |
3,999 |
$90K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,661 |
3,634 |
$55K |
| D0272 |
Bitewings - two radiographic images |
3,193 |
3,166 |
$38K |
| D1351 |
Sealant - per tooth |
1,024 |
216 |
$31K |
| D1110 |
Prophylaxis - adult |
286 |
286 |
$26K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
312 |
171 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
12 |
$2K |
| D2140 |
|
27 |
14 |
$1K |
| D9430 |
|
41 |
41 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
86 |
$1K |
| D0350 |
|
26 |
13 |
$231.60 |