| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,212 |
3,205 |
$169K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,635 |
1,627 |
$101K |
| D1120 |
Prophylaxis - child |
2,596 |
2,581 |
$93K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19,504 |
3,880 |
$80K |
| D0210 |
Intraoral - complete series of radiographic images |
1,195 |
1,183 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,616 |
2,603 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
591 |
289 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,362 |
2,350 |
$25K |
| D4910 |
|
256 |
255 |
$20K |
| D1351 |
Sealant - per tooth |
811 |
237 |
$19K |
| D4341 |
|
251 |
65 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
243 |
141 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
74 |
37 |
$9K |
| D0272 |
Bitewings - two radiographic images |
539 |
536 |
$6K |
| D0350 |
|
573 |
169 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
41 |
$3K |
| D1110 |
Prophylaxis - adult |
31 |
30 |
$2K |
| D1206 |
Topical application of fluoride varnish |
76 |
73 |
$672.00 |
| D0340 |
|
13 |
13 |
$650.00 |