| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,710 |
2,688 |
$555K |
| D0120 |
Periodic oral evaluation - established patient |
2,214 |
2,195 |
$374K |
| D1351 |
Sealant - per tooth |
10,267 |
2,466 |
$92K |
| D1120 |
Prophylaxis - child |
4,961 |
4,918 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
722 |
394 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,400 |
4,628 |
$29K |
| D1206 |
Topical application of fluoride varnish |
5,149 |
5,106 |
$26K |
| D0272 |
Bitewings - two radiographic images |
2,421 |
2,398 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
4,692 |
4,651 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
383 |
223 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
837 |
477 |
$11K |
| D0274 |
Bitewings - four radiographic images |
1,425 |
1,420 |
$7K |
| D2140 |
|
686 |
435 |
$4K |
| D1110 |
Prophylaxis - adult |
91 |
91 |
$2K |
| D2330 |
|
21 |
19 |
$384.85 |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
28 |
$164.20 |
| D2160 |
|
25 |
14 |
$155.23 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$0.00 |