| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
944 |
940 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,143 |
1,136 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
989 |
985 |
$20K |
| D1110 |
Prophylaxis - adult |
891 |
890 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
299 |
141 |
$13K |
| D1330 |
|
1,285 |
1,284 |
$5K |
| D2140 |
|
189 |
83 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
56 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
54 |
25 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
130 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
15 |
$2K |
| D1351 |
Sealant - per tooth |
374 |
84 |
$1K |
| D0330 |
Panoramic radiographic image |
32 |
31 |
$1K |
| D0274 |
Bitewings - four radiographic images |
665 |
662 |
$657.25 |
| D1120 |
Prophylaxis - child |
363 |
362 |
$582.43 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$250.09 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,329 |
1,327 |
$151.85 |
| D0220 |
Intraoral - periapical first radiographic image |
965 |
955 |
$90.83 |
| D0230 |
Intraoral - periapical each additional radiographic image |
910 |
870 |
$55.92 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$0.00 |