| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,759 |
2,679 |
$189K |
| D0120 |
Periodic oral evaluation - established patient |
2,592 |
2,553 |
$85K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
585 |
273 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
266 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,447 |
2,394 |
$21K |
| D0272 |
Bitewings - two radiographic images |
2,293 |
2,257 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,796 |
2,737 |
$16K |
| D1206 |
Topical application of fluoride varnish |
2,385 |
2,353 |
$14K |
| D0274 |
Bitewings - four radiographic images |
177 |
175 |
$14K |
| D0330 |
Panoramic radiographic image |
104 |
104 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
254 |
244 |
$9K |
| D1351 |
Sealant - per tooth |
193 |
69 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
241 |
106 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
24 |
$5K |
| D2140 |
|
58 |
27 |
$4K |
| D1110 |
Prophylaxis - adult |
14 |
12 |
$358.67 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |