| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,263 |
1,257 |
$46K |
| D1120 |
Prophylaxis - child |
1,487 |
1,479 |
$43K |
| D1351 |
Sealant - per tooth |
1,313 |
310 |
$28K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
353 |
184 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
382 |
379 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,152 |
1,149 |
$13K |
| D1110 |
Prophylaxis - adult |
216 |
215 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,777 |
1,249 |
$12K |
| D9430 |
|
339 |
329 |
$10K |
| D2940 |
|
175 |
81 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
110 |
$10K |
| D9110 |
|
159 |
147 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
763 |
674 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
40 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
375 |
373 |
$3K |
| D2140 |
|
33 |
12 |
$2K |
| D0350 |
|
20 |
12 |
$54.00 |