| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,930 |
4,902 |
$254K |
| D1120 |
Prophylaxis - child |
4,655 |
4,632 |
$170K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,833 |
5,342 |
$107K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,075 |
537 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,062 |
1,054 |
$65K |
| D0274 |
Bitewings - four radiographic images |
3,003 |
2,982 |
$62K |
| D1110 |
Prophylaxis - adult |
730 |
727 |
$57K |
| D2330 |
|
668 |
325 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
789 |
352 |
$50K |
| D9430 |
|
1,562 |
1,531 |
$49K |
| D1351 |
Sealant - per tooth |
1,897 |
419 |
$46K |
| D9951 |
|
1,693 |
1,668 |
$44K |
| D1206 |
Topical application of fluoride varnish |
3,397 |
3,385 |
$42K |
| D0350 |
|
4,049 |
1,536 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,950 |
2,702 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
716 |
714 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,493 |
2,474 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
364 |
244 |
$20K |
| D9110 |
|
288 |
281 |
$18K |
| D4910 |
|
153 |
151 |
$12K |
| D9993 |
|
233 |
233 |
$11K |
| D1310 |
|
244 |
244 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
71 |
$6K |
| D2160 |
|
61 |
43 |
$5K |
| D4341 |
|
96 |
28 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
29 |
$4K |
| D0272 |
Bitewings - two radiographic images |
369 |
369 |
$4K |
| D2335 |
|
18 |
12 |
$2K |
| D2920 |
|
28 |
24 |
$1K |
| D4342 |
|
35 |
12 |
$1K |
| D1354 |
|
12 |
12 |
$420.00 |
| D0603 |
|
25 |
25 |
$375.00 |