| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,682 |
3,673 |
$225K |
| D1110 |
Prophylaxis - adult |
1,988 |
1,983 |
$170K |
| D1120 |
Prophylaxis - child |
3,352 |
3,345 |
$133K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,834 |
1,831 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,376 |
842 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,362 |
700 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,415 |
5,402 |
$73K |
| D0274 |
Bitewings - four radiographic images |
2,975 |
2,967 |
$62K |
| D0210 |
Intraoral - complete series of radiographic images |
902 |
900 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,403 |
4,255 |
$34K |
| D9430 |
|
523 |
520 |
$16K |
| D0272 |
Bitewings - two radiographic images |
904 |
904 |
$11K |
| D0330 |
Panoramic radiographic image |
185 |
185 |
$5K |
| D1351 |
Sealant - per tooth |
137 |
32 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
432 |
430 |
$5K |
| D4341 |
|
35 |
12 |
$2K |
| D0350 |
|
21 |
16 |
$404.40 |