| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,336 |
6,269 |
$155K |
| D1110 |
Prophylaxis - adult |
4,670 |
4,609 |
$92K |
| D2750 |
|
232 |
170 |
$92K |
| D1120 |
Prophylaxis - child |
3,543 |
3,516 |
$76K |
| D1351 |
Sealant - per tooth |
5,140 |
838 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,118 |
7,541 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,154 |
652 |
$46K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,051 |
641 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,609 |
4,541 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,466 |
1,445 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
8,483 |
8,130 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
940 |
940 |
$28K |
| D4341 |
|
499 |
179 |
$22K |
| D9920 |
|
1,245 |
1,214 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
845 |
813 |
$17K |
| D2140 |
|
363 |
237 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
259 |
151 |
$12K |
| D2160 |
|
189 |
135 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
175 |
114 |
$7K |
| D0274 |
Bitewings - four radiographic images |
1,191 |
1,149 |
$6K |
| D2954 |
|
38 |
36 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
46 |
29 |
$2K |
| D0330 |
Panoramic radiographic image |
810 |
789 |
$2K |
| D0272 |
Bitewings - two radiographic images |
143 |
142 |
$656.25 |
| D2950 |
|
18 |
13 |
$486.00 |
| D1999 |
|
745 |
616 |
$0.00 |