| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
9,801 |
9,801 |
$280K |
| D1120 |
Prophylaxis - child |
7,381 |
7,381 |
$194K |
| D1110 |
Prophylaxis - adult |
2,553 |
2,553 |
$90K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,087 |
8,087 |
$90K |
| D1206 |
Topical application of fluoride varnish |
2,949 |
2,949 |
$68K |
| D0274 |
Bitewings - four radiographic images |
2,340 |
2,340 |
$60K |
| D0140 |
Limited oral evaluation - problem focused |
891 |
867 |
$26K |
| D0330 |
Panoramic radiographic image |
291 |
291 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
234 |
107 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
712 |
701 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
177 |
177 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
122 |
122 |
$2K |