| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,414 |
2,411 |
$124K |
| D1110 |
Prophylaxis - adult |
1,436 |
1,430 |
$115K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,731 |
1,724 |
$106K |
| D1120 |
Prophylaxis - child |
2,252 |
2,243 |
$84K |
| D4910 |
|
850 |
847 |
$64K |
| D1206 |
Topical application of fluoride varnish |
3,866 |
3,856 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
1,077 |
1,075 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
599 |
269 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,547 |
3,587 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,851 |
1,846 |
$35K |
| D2161 |
|
399 |
181 |
$33K |
| D4341 |
|
377 |
105 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
223 |
128 |
$17K |
| D2160 |
|
211 |
109 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,270 |
1,267 |
$14K |
| D1351 |
Sealant - per tooth |
602 |
151 |
$13K |
| D9430 |
|
266 |
248 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
109 |
51 |
$7K |
| D2394 |
|
22 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
121 |
$1K |
| D1310 |
|
27 |
27 |
$1K |
| D9993 |
|
14 |
14 |
$910.00 |
| D0350 |
|
93 |
56 |
$825.60 |