| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,841 |
3,841 |
$160K |
| D1120 |
Prophylaxis - child |
2,975 |
2,974 |
$130K |
| D1351 |
Sealant - per tooth |
1,639 |
523 |
$56K |
| D1110 |
Prophylaxis - adult |
1,035 |
1,035 |
$52K |
| D0272 |
Bitewings - two radiographic images |
2,366 |
2,366 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,340 |
2,340 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,574 |
1,573 |
$29K |
| D0274 |
Bitewings - four radiographic images |
936 |
936 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
943 |
942 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
174 |
113 |
$12K |
| D1353 |
|
566 |
192 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
98 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
108 |
78 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
165 |
165 |
$5K |
| D1354 |
|
116 |
29 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
132 |
132 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$193.00 |
| D0603 |
|
1,383 |
1,383 |
$0.00 |
| D1330 |
|
1,590 |
1,590 |
$0.00 |
| D0602 |
|
27 |
27 |
$0.00 |
| D0601 |
|
27 |
27 |
$0.00 |
| D1310 |
|
107 |
107 |
$0.00 |
| D1999 |
|
1,579 |
1,547 |
$0.00 |