| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,146 |
2,139 |
$186K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
721 |
719 |
$70K |
| D1120 |
Prophylaxis - child |
2,556 |
2,542 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,744 |
1,734 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,631 |
2,580 |
$19K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
302 |
173 |
$19K |
| D1351 |
Sealant - per tooth |
928 |
205 |
$18K |
| D1206 |
Topical application of fluoride varnish |
2,694 |
2,679 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
151 |
82 |
$13K |
| D0274 |
Bitewings - four radiographic images |
542 |
540 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,415 |
2,305 |
$11K |
| D2140 |
|
84 |
46 |
$5K |
| D1110 |
Prophylaxis - adult |
140 |
140 |
$5K |
| D0330 |
Panoramic radiographic image |
63 |
63 |
$4K |