| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,532 |
3,529 |
$231K |
| D1110 |
Prophylaxis - adult |
2,614 |
2,612 |
$227K |
| D0230 |
Intraoral - periapical each additional radiographic image |
31,940 |
4,765 |
$126K |
| D1120 |
Prophylaxis - child |
1,858 |
1,856 |
$75K |
| D4341 |
|
673 |
176 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
721 |
720 |
$42K |
| D1206 |
Topical application of fluoride varnish |
2,776 |
2,774 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,627 |
1,626 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,066 |
2,066 |
$28K |
| D0272 |
Bitewings - two radiographic images |
2,367 |
2,367 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
541 |
310 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,561 |
1,518 |
$18K |
| D0350 |
|
1,797 |
898 |
$17K |
| D4910 |
|
178 |
178 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
303 |
302 |
$13K |
| D1351 |
Sealant - per tooth |
227 |
56 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
70 |
$6K |
| D2330 |
|
74 |
43 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
54 |
44 |
$4K |
| D9430 |
|
65 |
64 |
$2K |