| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,616 |
2,604 |
$145K |
| D1120 |
Prophylaxis - child |
2,597 |
2,574 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,343 |
659 |
$88K |
| D0274 |
Bitewings - four radiographic images |
1,691 |
1,680 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,926 |
2,912 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,380 |
2,916 |
$34K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
410 |
202 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
270 |
146 |
$14K |
| D1351 |
Sealant - per tooth |
395 |
127 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
52 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
53 |
$5K |
| D4910 |
|
55 |
55 |
$4K |
| D0350 |
|
403 |
249 |
$4K |
| D0272 |
Bitewings - two radiographic images |
335 |
334 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
62 |
$3K |
| D2160 |
|
19 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
82 |
$958.00 |
| D9430 |
|
15 |
15 |
$420.00 |