| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,750 |
2,738 |
$138K |
| D1110 |
Prophylaxis - adult |
1,168 |
1,167 |
$98K |
| D1120 |
Prophylaxis - child |
2,401 |
2,389 |
$81K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,104 |
1,100 |
$67K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,251 |
2,736 |
$66K |
| D0210 |
Intraoral - complete series of radiographic images |
1,274 |
1,274 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,826 |
3,811 |
$44K |
| D1351 |
Sealant - per tooth |
1,875 |
401 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
1,682 |
1,532 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,703 |
1,694 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
325 |
221 |
$18K |
| D9993 |
|
1,006 |
1,003 |
$9K |
| D4910 |
|
104 |
104 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
120 |
96 |
$8K |
| D9430 |
|
238 |
235 |
$7K |
| D1310 |
|
1,016 |
1,010 |
$7K |
| D4341 |
|
85 |
29 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
39 |
$4K |
| D0350 |
|
235 |
154 |
$2K |
| D2330 |
|
22 |
14 |
$2K |
| D2954 |
|
14 |
12 |
$1K |
| D0601 |
|
856 |
854 |
$1K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$1K |
| D0602 |
|
12 |
12 |
$90.00 |
| D1330 |
|
19 |
19 |
$0.00 |