| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,990 |
1,976 |
$120K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
888 |
873 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
536 |
278 |
$31K |
| D1120 |
Prophylaxis - child |
2,215 |
2,187 |
$29K |
| D1351 |
Sealant - per tooth |
3,370 |
709 |
$25K |
| D1110 |
Prophylaxis - adult |
440 |
437 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
319 |
310 |
$17K |
| D0274 |
Bitewings - four radiographic images |
2,233 |
2,216 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,698 |
2,669 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
201 |
114 |
$6K |
| D1330 |
|
2,794 |
2,754 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
2,779 |
2,726 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,594 |
2,524 |
$2K |
| D0999 |
Unspecified diagnostic procedure, by report |
35 |
35 |
$700.00 |
| D1999 |
|
28 |
28 |
$560.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$533.11 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$503.70 |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$325.00 |