| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,918 |
3,916 |
$140K |
| D1120 |
Prophylaxis - child |
3,221 |
3,215 |
$120K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,150 |
868 |
$75K |
| D1206 |
Topical application of fluoride varnish |
3,608 |
3,600 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
882 |
611 |
$46K |
| D1110 |
Prophylaxis - adult |
641 |
637 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,385 |
1,384 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
489 |
487 |
$25K |
| D4910 |
|
312 |
312 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,756 |
2,376 |
$19K |
| D0350 |
|
1,911 |
1,155 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
335 |
329 |
$15K |
| D9430 |
|
375 |
363 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
820 |
801 |
$11K |
| D1351 |
Sealant - per tooth |
352 |
132 |
$9K |
| D1310 |
|
98 |
97 |
$6K |
| D2330 |
|
51 |
39 |
$4K |
| D0272 |
Bitewings - two radiographic images |
232 |
230 |
$3K |
| D4341 |
|
26 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$2K |
| D0603 |
|
62 |
62 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$957.60 |