| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,101 |
2,098 |
$119K |
| D1110 |
Prophylaxis - adult |
1,229 |
1,224 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,153 |
1,146 |
$72K |
| D1120 |
Prophylaxis - child |
1,353 |
1,351 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
857 |
260 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,838 |
2,829 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
705 |
699 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,906 |
2,559 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,471 |
1,470 |
$30K |
| D4341 |
|
373 |
96 |
$25K |
| D0350 |
|
978 |
382 |
$10K |
| D1351 |
Sealant - per tooth |
210 |
40 |
$6K |
| D1320 |
|
201 |
201 |
$4K |
| D4910 |
|
26 |
26 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
28 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
119 |
118 |
$1K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$995.00 |
| D9430 |
|
12 |
12 |
$384.00 |