| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,723 |
2,723 |
$105K |
| D1120 |
Prophylaxis - child |
2,864 |
2,846 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,144 |
669 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
774 |
446 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,729 |
2,708 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
445 |
259 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
431 |
430 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,674 |
2,640 |
$21K |
| D9430 |
|
704 |
681 |
$21K |
| D0274 |
Bitewings - four radiographic images |
940 |
934 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,216 |
1,212 |
$14K |
| D1351 |
Sealant - per tooth |
604 |
198 |
$13K |
| D1110 |
Prophylaxis - adult |
133 |
130 |
$8K |
| D0350 |
|
802 |
425 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
565 |
552 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
130 |
129 |
$5K |
| D1206 |
Topical application of fluoride varnish |
375 |
375 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
25 |
$2K |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$364.00 |