| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,062 |
1,054 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,610 |
2,135 |
$44K |
| D1120 |
Prophylaxis - child |
1,082 |
1,082 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,303 |
1,292 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
283 |
$18K |
| D9430 |
|
521 |
427 |
$16K |
| D1351 |
Sealant - per tooth |
547 |
135 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,142 |
1,134 |
$10K |
| D0350 |
|
797 |
303 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
80 |
52 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
354 |
312 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
24 |
$4K |
| D2140 |
|
47 |
28 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
15 |
$2K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$764.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$672.00 |
| D9993 |
|
34 |
34 |
$260.00 |
| D1310 |
|
34 |
34 |
$258.00 |
| D1999 |
|
18 |
18 |
$0.00 |
| D0601 |
|
17 |
17 |
$0.00 |