| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,474 |
5,474 |
$190K |
| D1110 |
Prophylaxis - adult |
3,387 |
3,387 |
$167K |
| D1206 |
Topical application of fluoride varnish |
7,533 |
7,533 |
$122K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,785 |
2,785 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
4,435 |
4,435 |
$101K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,146 |
512 |
$93K |
| D1351 |
Sealant - per tooth |
2,664 |
870 |
$80K |
| D0330 |
Panoramic radiographic image |
1,472 |
1,472 |
$70K |
| D0272 |
Bitewings - two radiographic images |
3,731 |
3,731 |
$69K |
| D0274 |
Bitewings - four radiographic images |
2,597 |
2,597 |
$67K |
| D0140 |
Limited oral evaluation - problem focused |
1,317 |
1,315 |
$49K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
428 |
326 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,581 |
1,571 |
$18K |
| D0240 |
|
683 |
368 |
$13K |
| D2160 |
|
70 |
61 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$1K |
| D2140 |
|
14 |
13 |
$845.06 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$815.55 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
28 |
$288.46 |