| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
8,788 |
8,782 |
$726K |
| D1351 |
Sealant - per tooth |
6,131 |
1,008 |
$224K |
| D1120 |
Prophylaxis - child |
8,663 |
8,657 |
$167K |
| D1206 |
Topical application of fluoride varnish |
9,357 |
9,350 |
$84K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,561 |
4,199 |
$69K |
| D0220 |
Intraoral - periapical first radiographic image |
5,187 |
5,148 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
556 |
556 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
533 |
331 |
$49K |
| D0272 |
Bitewings - two radiographic images |
3,939 |
3,935 |
$48K |
| D0330 |
Panoramic radiographic image |
1,291 |
1,290 |
$46K |
| D0274 |
Bitewings - four radiographic images |
2,372 |
2,372 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
437 |
312 |
$34K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
624 |
351 |
$23K |
| D1110 |
Prophylaxis - adult |
692 |
692 |
$21K |
| D2140 |
|
436 |
310 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
281 |
276 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
161 |
100 |
$8K |
| D9248 |
|
13 |
13 |
$255.18 |