| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,747 |
2,734 |
$177K |
| D1110 |
Prophylaxis - adult |
1,192 |
1,186 |
$107K |
| D1120 |
Prophylaxis - child |
2,679 |
2,664 |
$106K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,830 |
4,171 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,114 |
1,106 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,962 |
3,941 |
$49K |
| D0272 |
Bitewings - two radiographic images |
3,812 |
3,792 |
$46K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
513 |
272 |
$34K |
| D9430 |
|
672 |
659 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
316 |
132 |
$21K |
| D1351 |
Sealant - per tooth |
657 |
141 |
$16K |
| D0350 |
|
1,461 |
563 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
78 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
26 |
$3K |
| D2140 |
|
42 |
26 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
24 |
$2K |
| D2160 |
|
17 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$456.00 |