| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,604 |
1,596 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,228 |
1,228 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,064 |
624 |
$58K |
| D1120 |
Prophylaxis - child |
1,356 |
1,352 |
$58K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,698 |
2,527 |
$52K |
| D0210 |
Intraoral - complete series of radiographic images |
904 |
904 |
$43K |
| D0350 |
|
4,163 |
1,771 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
516 |
365 |
$34K |
| D9430 |
|
849 |
832 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,235 |
1,231 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,805 |
1,798 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,781 |
1,750 |
$21K |
| D1110 |
Prophylaxis - adult |
201 |
200 |
$17K |
| D4341 |
|
63 |
28 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
14 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |