| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,720 |
2,718 |
$112K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,552 |
1,549 |
$95K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24,002 |
4,289 |
$94K |
| D1120 |
Prophylaxis - child |
2,631 |
2,631 |
$78K |
| D1351 |
Sealant - per tooth |
3,403 |
887 |
$72K |
| D1110 |
Prophylaxis - adult |
675 |
675 |
$59K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
755 |
395 |
$50K |
| D0272 |
Bitewings - two radiographic images |
2,929 |
2,927 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,379 |
3,379 |
$33K |
| D2140 |
|
483 |
253 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,001 |
998 |
$21K |
| D0350 |
|
709 |
361 |
$6K |
| D4341 |
|
44 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
28 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$810.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$168.00 |