| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,663 |
2,654 |
$189K |
| D1120 |
Prophylaxis - child |
2,834 |
2,825 |
$126K |
| D1110 |
Prophylaxis - adult |
1,177 |
1,172 |
$103K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,469 |
1,468 |
$96K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,044 |
3,594 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,022 |
608 |
$67K |
| D0210 |
Intraoral - complete series of radiographic images |
1,253 |
1,248 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
703 |
444 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,709 |
1,705 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,618 |
2,618 |
$32K |
| D1351 |
Sealant - per tooth |
915 |
265 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,303 |
1,293 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,402 |
1,313 |
$17K |
| D9430 |
|
330 |
312 |
$11K |
| D0272 |
Bitewings - two radiographic images |
868 |
866 |
$10K |
| D4910 |
|
118 |
113 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
59 |
26 |
$7K |
| D9110 |
|
87 |
78 |
$5K |
| D4341 |
|
48 |
13 |
$3K |
| D1310 |
|
74 |
74 |
$644.00 |
| D0350 |
|
272 |
93 |
$144.00 |
| D0601 |
|
72 |
72 |
$0.00 |