| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,123 |
5,113 |
$306K |
| D1120 |
Prophylaxis - child |
5,503 |
5,487 |
$222K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45,354 |
8,357 |
$187K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,712 |
1,263 |
$181K |
| D1110 |
Prophylaxis - adult |
1,900 |
1,891 |
$166K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,211 |
2,204 |
$142K |
| D0274 |
Bitewings - four radiographic images |
6,277 |
6,255 |
$132K |
| D1206 |
Topical application of fluoride varnish |
4,912 |
4,903 |
$67K |
| D1351 |
Sealant - per tooth |
1,697 |
415 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,025 |
514 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,614 |
2,593 |
$30K |
| D0350 |
|
2,538 |
1,274 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
125 |
84 |
$10K |
| D7240 |
Removal of impacted tooth - completely bony |
42 |
14 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
106 |
48 |
$7K |
| D0272 |
Bitewings - two radiographic images |
396 |
395 |
$5K |
| D7230 |
|
20 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
119 |
119 |
$4K |
| D4341 |
|
46 |
12 |
$3K |
| D9430 |
|
82 |
81 |
$3K |
| D2140 |
|
22 |
14 |
$1K |
| D1310 |
|
12 |
12 |
$552.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$120.00 |