| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,329 |
5,295 |
$277K |
| D1120 |
Prophylaxis - child |
5,821 |
5,775 |
$215K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,822 |
1,820 |
$110K |
| D1110 |
Prophylaxis - adult |
1,097 |
1,093 |
$89K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,099 |
5,348 |
$88K |
| D1206 |
Topical application of fluoride varnish |
6,504 |
6,463 |
$85K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,523 |
771 |
$82K |
| D0210 |
Intraoral - complete series of radiographic images |
1,455 |
1,451 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
939 |
579 |
$62K |
| D0220 |
Intraoral - periapical first radiographic image |
3,157 |
3,126 |
$36K |
| D9430 |
|
1,128 |
1,109 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,558 |
1,552 |
$32K |
| D0350 |
|
2,602 |
1,047 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
424 |
259 |
$24K |
| D0330 |
Panoramic radiographic image |
705 |
704 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
233 |
232 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
272 |
271 |
$3K |
| D1351 |
Sealant - per tooth |
62 |
13 |
$1K |
| D0270 |
|
33 |
33 |
$155.00 |
| D1330 |
|
1,600 |
1,584 |
$0.00 |