| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,329 |
5,301 |
$300K |
| D1120 |
Prophylaxis - child |
5,819 |
5,787 |
$222K |
| D1351 |
Sealant - per tooth |
4,646 |
1,162 |
$128K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26,700 |
5,350 |
$109K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,485 |
6,448 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,170 |
1,163 |
$77K |
| D1110 |
Prophylaxis - adult |
717 |
712 |
$64K |
| D0210 |
Intraoral - complete series of radiographic images |
1,096 |
1,091 |
$52K |
| D0272 |
Bitewings - two radiographic images |
3,446 |
3,428 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,150 |
1,143 |
$24K |
| D1310 |
|
464 |
461 |
$21K |
| D0350 |
|
2,185 |
1,149 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
288 |
161 |
$19K |
| D9993 |
|
227 |
227 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
94 |
$10K |
| D0601 |
|
217 |
216 |
$3K |
| D2160 |
|
19 |
12 |
$2K |
| D9430 |
|
27 |
26 |
$864.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$819.00 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$633.00 |
| D1999 |
|
37 |
37 |
$0.00 |