| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,721 |
2,720 |
$65K |
| D1120 |
Prophylaxis - child |
1,793 |
1,793 |
$54K |
| D1110 |
Prophylaxis - adult |
1,723 |
1,722 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,733 |
1,733 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,202 |
2,201 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
738 |
738 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
335 |
190 |
$19K |
| D1351 |
Sealant - per tooth |
1,136 |
229 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
584 |
573 |
$15K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
34 |
24 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
2,734 |
2,636 |
$13K |
| D9920 |
|
707 |
630 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,076 |
2,041 |
$9K |
| D0330 |
Panoramic radiographic image |
136 |
136 |
$4K |
| D0601 |
|
298 |
298 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
24 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
14 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
14 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
13 |
$960.00 |
| D9110 |
|
12 |
12 |
$160.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$81.35 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$0.00 |