| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,339 |
2,315 |
$148K |
| D0220 |
Intraoral - periapical first radiographic image |
2,219 |
2,185 |
$37K |
| D0330 |
Panoramic radiographic image |
534 |
526 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
404 |
267 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
283 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,655 |
2,624 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
280 |
168 |
$10K |
| D0274 |
Bitewings - four radiographic images |
1,033 |
1,020 |
$8K |
| D1110 |
Prophylaxis - adult |
1,021 |
1,003 |
$4K |
| D1351 |
Sealant - per tooth |
827 |
242 |
$4K |
| D0272 |
Bitewings - two radiographic images |
492 |
484 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
13 |
$3K |
| D1120 |
Prophylaxis - child |
1,136 |
1,124 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,112 |
2,073 |
$2K |
| D1330 |
|
2,679 |
2,648 |
$897.75 |
| D9920 |
|
56 |
54 |
$463.71 |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$0.00 |
| D3120 |
|
23 |
14 |
$0.00 |