| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,563 |
2,503 |
$70K |
| D1120 |
Prophylaxis - child |
1,412 |
1,393 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,349 |
1,330 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,344 |
1,306 |
$23K |
| D1351 |
Sealant - per tooth |
257 |
165 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
145 |
107 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
193 |
128 |
$13K |
| D1110 |
Prophylaxis - adult |
291 |
288 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,301 |
1,259 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
38 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
837 |
821 |
$4K |
| D2332 |
|
18 |
16 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
105 |
$2K |
| D4342 |
|
20 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
188 |
186 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
66 |
$1K |
| D2140 |
|
23 |
17 |
$956.35 |
| D9110 |
|
16 |
13 |
$880.00 |