| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,912 |
3,840 |
$199K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
696 |
686 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,517 |
719 |
$57K |
| D0330 |
Panoramic radiographic image |
1,200 |
1,180 |
$54K |
| D9920 |
|
435 |
424 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,134 |
633 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
156 |
93 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
545 |
536 |
$10K |
| D1120 |
Prophylaxis - child |
2,862 |
2,814 |
$8K |
| D1351 |
Sealant - per tooth |
4,195 |
1,265 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,968 |
4,880 |
$5K |
| D1110 |
Prophylaxis - adult |
1,836 |
1,806 |
$3K |
| D1330 |
|
5,087 |
4,999 |
$3K |
| D4355 |
|
126 |
106 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,492 |
1,469 |
$1K |
| D0272 |
Bitewings - two radiographic images |
394 |
389 |
$248.48 |
| D0220 |
Intraoral - periapical first radiographic image |
2,315 |
2,269 |
$234.06 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,105 |
2,067 |
$8.96 |
| D9995 |
|
116 |
116 |
$0.00 |
| D1999 |
|
14 |
14 |
$0.00 |