| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,321 |
3,313 |
$179K |
| D1120 |
Prophylaxis - child |
3,188 |
3,181 |
$120K |
| D1351 |
Sealant - per tooth |
2,442 |
608 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,694 |
2,687 |
$57K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,210 |
4,531 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,617 |
3,605 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
516 |
250 |
$35K |
| D9430 |
|
933 |
889 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
430 |
428 |
$28K |
| D1110 |
Prophylaxis - adult |
273 |
273 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
296 |
158 |
$16K |
| D0272 |
Bitewings - two radiographic images |
959 |
952 |
$11K |
| D0330 |
Panoramic radiographic image |
333 |
332 |
$10K |
| D7240 |
Removal of impacted tooth - completely bony |
40 |
15 |
$9K |
| D4910 |
|
68 |
68 |
$5K |
| D0350 |
|
320 |
157 |
$3K |
| D2952 |
|
16 |
13 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
64 |
$748.00 |