| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
11,243 |
11,056 |
$108K |
| D1110 |
Prophylaxis - adult |
8,039 |
7,885 |
$84K |
| D2750 |
|
345 |
288 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,705 |
9,517 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,378 |
1,417 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,542 |
1,055 |
$30K |
| D1351 |
Sealant - per tooth |
4,549 |
797 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
972 |
693 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
1,600 |
1,547 |
$22K |
| D1120 |
Prophylaxis - child |
2,447 |
2,416 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
9,553 |
9,386 |
$20K |
| D0272 |
Bitewings - two radiographic images |
4,150 |
4,093 |
$14K |
| D2332 |
|
489 |
272 |
$13K |
| D2335 |
|
228 |
103 |
$10K |
| D1206 |
Topical application of fluoride varnish |
469 |
445 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
482 |
482 |
$4K |
| D2954 |
|
67 |
54 |
$2K |
| D2140 |
|
118 |
82 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
84 |
52 |
$1K |
| D4341 |
|
34 |
12 |
$760.00 |
| D0330 |
Panoramic radiographic image |
219 |
219 |
$372.00 |
| D2330 |
|
16 |
12 |
$223.00 |
| D9110 |
|
29 |
29 |
$212.50 |
| D0270 |
|
5,797 |
3,406 |
$142.50 |