| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,574 |
2,573 |
$153K |
| D1110 |
Prophylaxis - adult |
1,132 |
1,130 |
$97K |
| D1120 |
Prophylaxis - child |
2,321 |
2,320 |
$94K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,638 |
3,720 |
$84K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,566 |
3,565 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
710 |
709 |
$45K |
| D0274 |
Bitewings - four radiographic images |
2,117 |
2,117 |
$45K |
| D9430 |
|
1,178 |
1,013 |
$38K |
| D4910 |
|
353 |
353 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
449 |
152 |
$24K |
| D1351 |
Sealant - per tooth |
530 |
137 |
$15K |
| D4341 |
|
130 |
33 |
$9K |
| D0350 |
|
747 |
238 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
54 |
$6K |
| D0272 |
Bitewings - two radiographic images |
408 |
408 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
70 |
38 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
108 |
105 |
$1K |
| D1310 |
|
14 |
14 |
$644.00 |
| D0602 |
|
14 |
14 |
$210.00 |