| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,424 |
4,399 |
$238K |
| D1120 |
Prophylaxis - child |
3,981 |
3,961 |
$148K |
| D1110 |
Prophylaxis - adult |
1,080 |
1,071 |
$89K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,134 |
5,133 |
$68K |
| D0274 |
Bitewings - four radiographic images |
3,217 |
3,204 |
$68K |
| D1351 |
Sealant - per tooth |
2,502 |
695 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,846 |
3,827 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
476 |
472 |
$28K |
| D0272 |
Bitewings - two radiographic images |
774 |
768 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
506 |
501 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
53 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
44 |
21 |
$3K |
| D0350 |
|
202 |
95 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
14 |
$1K |
| D2160 |
|
16 |
13 |
$1K |
| D9430 |
|
26 |
26 |
$776.00 |