| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,109 |
1,101 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,689 |
2,320 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
677 |
675 |
$42K |
| D1120 |
Prophylaxis - child |
1,069 |
1,058 |
$40K |
| D1110 |
Prophylaxis - adult |
350 |
349 |
$30K |
| D9430 |
|
645 |
584 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,439 |
1,429 |
$19K |
| D4341 |
|
163 |
42 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
202 |
202 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
731 |
695 |
$9K |
| D0272 |
Bitewings - two radiographic images |
657 |
644 |
$7K |
| D2140 |
|
130 |
63 |
$7K |
| D0274 |
Bitewings - four radiographic images |
181 |
181 |
$4K |
| D0350 |
|
263 |
166 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
14 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
62 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
47 |
47 |
$657.00 |