| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,916 |
3,887 |
$317K |
| D1120 |
Prophylaxis - child |
3,945 |
3,918 |
$88K |
| D0220 |
Intraoral - periapical first radiographic image |
2,654 |
2,625 |
$54K |
| D1351 |
Sealant - per tooth |
2,329 |
454 |
$54K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
585 |
299 |
$44K |
| D1206 |
Topical application of fluoride varnish |
4,175 |
4,144 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
194 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,791 |
1,779 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,469 |
2,404 |
$8K |
| D0274 |
Bitewings - four radiographic images |
605 |
593 |
$5K |
| D2140 |
|
111 |
72 |
$5K |
| D0330 |
Panoramic radiographic image |
341 |
335 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
25 |
$3K |
| D1110 |
Prophylaxis - adult |
46 |
45 |
$413.98 |