| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,556 |
3,542 |
$202K |
| D1110 |
Prophylaxis - adult |
1,817 |
1,804 |
$154K |
| D1120 |
Prophylaxis - child |
3,195 |
3,187 |
$123K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28,960 |
5,342 |
$119K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,475 |
858 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,392 |
1,383 |
$89K |
| D1351 |
Sealant - per tooth |
2,551 |
739 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,163 |
657 |
$66K |
| D2140 |
|
1,221 |
688 |
$66K |
| D0274 |
Bitewings - four radiographic images |
2,938 |
2,918 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,805 |
4,784 |
$60K |
| D4341 |
|
769 |
196 |
$54K |
| D4910 |
|
689 |
683 |
$53K |
| D9110 |
|
525 |
524 |
$33K |
| D9430 |
|
597 |
597 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,378 |
1,375 |
$16K |
| D0350 |
|
1,371 |
487 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
258 |
258 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
679 |
678 |
$8K |
| D2330 |
|
35 |
24 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
24 |
$2K |
| D2160 |
|
14 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$176.00 |