| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
16,116 |
16,096 |
$396K |
| D1120 |
Prophylaxis - child |
10,993 |
10,985 |
$396K |
| D1110 |
Prophylaxis - adult |
6,330 |
6,323 |
$296K |
| D1351 |
Sealant - per tooth |
7,825 |
2,039 |
$285K |
| D0220 |
Intraoral - periapical first radiographic image |
13,102 |
13,071 |
$226K |
| D1208 |
Topical application of fluoride, excluding varnish |
15,198 |
15,179 |
$188K |
| D0274 |
Bitewings - four radiographic images |
4,618 |
4,613 |
$111K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,200 |
918 |
$101K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,398 |
948 |
$90K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,562 |
5,556 |
$85K |
| D0272 |
Bitewings - two radiographic images |
5,513 |
5,501 |
$83K |
| D0210 |
Intraoral - complete series of radiographic images |
3,127 |
3,126 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
792 |
566 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,173 |
1,171 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,057 |
1,056 |
$27K |
| D2394 |
|
73 |
51 |
$7K |
| D9110 |
|
40 |
39 |
$942.66 |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$710.94 |