| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,143 |
3,141 |
$188K |
| D1120 |
Prophylaxis - child |
3,387 |
3,383 |
$136K |
| D1351 |
Sealant - per tooth |
4,009 |
1,080 |
$117K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,490 |
1,489 |
$95K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,513 |
4,715 |
$91K |
| D0274 |
Bitewings - four radiographic images |
3,011 |
3,008 |
$63K |
| D0350 |
|
6,053 |
1,878 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,362 |
3,358 |
$41K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
544 |
303 |
$36K |
| D1110 |
Prophylaxis - adult |
356 |
356 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
405 |
405 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,463 |
1,406 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
156 |
$16K |
| D1206 |
Topical application of fluoride varnish |
576 |
576 |
$10K |
| D2140 |
|
175 |
113 |
$9K |
| D9430 |
|
287 |
278 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
102 |
$9K |
| D0272 |
Bitewings - two radiographic images |
221 |
221 |
$3K |
| D4341 |
|
34 |
12 |
$2K |
| D4910 |
|
15 |
15 |
$1K |
| D1310 |
|
12 |
12 |
$506.00 |