| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,407 |
2,405 |
$142K |
| D1120 |
Prophylaxis - child |
2,563 |
2,561 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
214 |
$34K |
| D1206 |
Topical application of fluoride varnish |
2,588 |
2,587 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,680 |
1,673 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,364 |
1,361 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,585 |
1,337 |
$19K |
| D1351 |
Sealant - per tooth |
934 |
207 |
$17K |
| D0274 |
Bitewings - four radiographic images |
629 |
629 |
$17K |
| D0330 |
Panoramic radiographic image |
261 |
261 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
41 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
52 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
86 |
42 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$2K |
| D2140 |
|
44 |
27 |
$2K |