| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,774 |
1,761 |
$92K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,481 |
1,473 |
$86K |
| D1120 |
Prophylaxis - child |
1,809 |
1,794 |
$66K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,649 |
3,053 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
647 |
331 |
$43K |
| D0272 |
Bitewings - two radiographic images |
2,575 |
2,555 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,919 |
1,902 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
305 |
302 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
102 |
$10K |
| D9430 |
|
315 |
311 |
$10K |
| D1110 |
Prophylaxis - adult |
120 |
120 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
25 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
256 |
251 |
$3K |
| D4341 |
|
37 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
111 |
25 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$880.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
13 |
$803.60 |
| D1330 |
|
13 |
13 |
$0.00 |