| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,412 |
3,410 |
$72K |
| D1110 |
Prophylaxis - adult |
2,481 |
2,466 |
$70K |
| D1120 |
Prophylaxis - child |
1,794 |
1,794 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,580 |
2,575 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,207 |
4,130 |
$34K |
| D1351 |
Sealant - per tooth |
1,882 |
332 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
4,640 |
4,501 |
$17K |
| D0330 |
Panoramic radiographic image |
487 |
486 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
190 |
100 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
550 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
386 |
229 |
$10K |
| D9920 |
|
586 |
571 |
$6K |
| D0274 |
Bitewings - four radiographic images |
527 |
525 |
$6K |
| D2140 |
|
138 |
87 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
108 |
105 |
$2K |
| D4341 |
|
84 |
42 |
$2K |
| D2160 |
|
75 |
64 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$200.00 |