| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,096 |
2,096 |
$43K |
| D1110 |
Prophylaxis - adult |
992 |
992 |
$36K |
| D1120 |
Prophylaxis - child |
964 |
964 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
484 |
337 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,386 |
1,386 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,352 |
1,352 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
381 |
276 |
$15K |
| D0330 |
Panoramic radiographic image |
674 |
674 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,997 |
1,375 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,230 |
1,221 |
$8K |
| D1351 |
Sealant - per tooth |
205 |
72 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
144 |
111 |
$6K |
| D9110 |
|
160 |
157 |
$3K |
| D0272 |
Bitewings - two radiographic images |
157 |
157 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
16 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
217 |
216 |
$1K |
| D0240 |
|
87 |
65 |
$450.66 |
| D0601 |
|
150 |
150 |
$84.00 |
| D0603 |
|
24 |
24 |
$9.00 |
| D0602 |
|
18 |
18 |
$8.00 |
| D1330 |
|
1,904 |
1,901 |
$0.00 |
| D1999 |
|
200 |
193 |
$0.00 |