| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,135 |
1,128 |
$59K |
| D1120 |
Prophylaxis - child |
1,176 |
1,166 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
696 |
691 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
444 |
249 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,230 |
1,635 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,694 |
1,681 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
363 |
359 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
159 |
86 |
$8K |
| D1351 |
Sealant - per tooth |
357 |
89 |
$8K |
| D0272 |
Bitewings - two radiographic images |
541 |
541 |
$6K |
| D0350 |
|
552 |
249 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
356 |
350 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
24 |
$2K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$885.60 |
| D4910 |
|
12 |
12 |
$869.00 |