| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,980 |
2,973 |
$159K |
| D1120 |
Prophylaxis - child |
2,830 |
2,822 |
$106K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,547 |
3,529 |
$74K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
857 |
497 |
$57K |
| D0274 |
Bitewings - four radiographic images |
1,782 |
1,781 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,736 |
2,729 |
$30K |
| D2160 |
|
278 |
201 |
$22K |
| D0272 |
Bitewings - two radiographic images |
870 |
869 |
$10K |
| D1351 |
Sealant - per tooth |
385 |
103 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
110 |
$6K |
| D1110 |
Prophylaxis - adult |
70 |
70 |
$5K |
| D1206 |
Topical application of fluoride varnish |
193 |
193 |
$3K |
| D2140 |
|
34 |
21 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$832.30 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$624.00 |
| D9430 |
|
12 |
12 |
$352.00 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
16 |
$204.00 |