| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,279 |
2,269 |
$190K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
479 |
224 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
221 |
$25K |
| D1120 |
Prophylaxis - child |
2,433 |
2,419 |
$23K |
| D1206 |
Topical application of fluoride varnish |
2,165 |
2,156 |
$10K |
| D0272 |
Bitewings - two radiographic images |
1,313 |
1,304 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,138 |
1,127 |
$5K |
| D2140 |
|
74 |
45 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,501 |
780 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
25 |
$3K |
| D1351 |
Sealant - per tooth |
65 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
88 |
88 |
$421.44 |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$135.06 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
100 |
97 |
$0.00 |