| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,663 |
3,649 |
$205K |
| D1120 |
Prophylaxis - child |
3,305 |
3,298 |
$126K |
| D1110 |
Prophylaxis - adult |
1,140 |
1,138 |
$96K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,656 |
3,458 |
$65K |
| D1351 |
Sealant - per tooth |
2,521 |
789 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,941 |
4,924 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
844 |
842 |
$52K |
| D0210 |
Intraoral - complete series of radiographic images |
1,104 |
1,102 |
$51K |
| D4910 |
|
666 |
659 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
607 |
293 |
$33K |
| D0272 |
Bitewings - two radiographic images |
2,771 |
2,764 |
$33K |
| D4341 |
|
440 |
117 |
$30K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
173 |
107 |
$11K |
| D9993 |
|
165 |
165 |
$11K |
| D1310 |
|
231 |
229 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
858 |
846 |
$10K |
| D2140 |
|
39 |
18 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
13 |
$1K |
| D0603 |
|
19 |
19 |
$285.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$280.80 |
| D0602 |
|
12 |
12 |
$180.00 |