| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,493 |
1,493 |
$59K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
841 |
445 |
$55K |
| D1120 |
Prophylaxis - child |
1,317 |
1,317 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
407 |
198 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
327 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,348 |
1,719 |
$17K |
| D0274 |
Bitewings - four radiographic images |
788 |
787 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,309 |
1,309 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
79 |
$8K |
| D0272 |
Bitewings - two radiographic images |
655 |
654 |
$7K |
| D2140 |
|
103 |
70 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
32 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
236 |
234 |
$3K |
| D1351 |
Sealant - per tooth |
57 |
12 |
$1K |
| D9430 |
|
27 |
27 |
$864.00 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$680.00 |