| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,075 |
5,033 |
$298K |
| D1110 |
Prophylaxis - adult |
3,234 |
3,215 |
$279K |
| D4910 |
|
2,548 |
2,548 |
$196K |
| D0230 |
Intraoral - periapical each additional radiographic image |
40,320 |
6,189 |
$163K |
| D4341 |
|
2,237 |
602 |
$150K |
| D1120 |
Prophylaxis - child |
2,708 |
2,681 |
$101K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,940 |
5,894 |
$75K |
| D0272 |
Bitewings - two radiographic images |
3,825 |
3,777 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,957 |
1,956 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
641 |
638 |
$40K |
| D1351 |
Sealant - per tooth |
1,387 |
313 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
433 |
199 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
989 |
971 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
135 |
102 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
16 |
$2K |
| D9430 |
|
58 |
52 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$768.00 |