| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,825 |
1,823 |
$104K |
| D1120 |
Prophylaxis - child |
2,048 |
2,042 |
$79K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,271 |
2,262 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,603 |
1,058 |
$9K |
| D0274 |
Bitewings - four radiographic images |
386 |
381 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
34 |
17 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
54 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
65 |
$712.00 |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$440.00 |
| D9430 |
|
13 |
13 |
$416.00 |
| D0350 |
|
19 |
13 |
$120.00 |
| D1999 |
|
164 |
164 |
$92.00 |
| D0190 |
|
63 |
63 |
$0.00 |