| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,801 |
3,766 |
$204K |
| D1120 |
Prophylaxis - child |
3,679 |
3,655 |
$135K |
| D1110 |
Prophylaxis - adult |
871 |
862 |
$74K |
| D1351 |
Sealant - per tooth |
2,442 |
787 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
933 |
926 |
$58K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
767 |
440 |
$51K |
| D0274 |
Bitewings - four radiographic images |
2,270 |
2,254 |
$48K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,544 |
4,141 |
$47K |
| D1206 |
Topical application of fluoride varnish |
2,296 |
2,275 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,485 |
2,476 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,545 |
1,536 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
263 |
173 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
369 |
360 |
$17K |
| D9993 |
|
235 |
234 |
$12K |
| D1310 |
|
264 |
264 |
$12K |
| D9430 |
|
296 |
287 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
52 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
449 |
443 |
$5K |
| D0350 |
|
381 |
216 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$1K |
| D2140 |
|
21 |
12 |
$1K |
| D0603 |
|
67 |
67 |
$735.00 |
| D1354 |
|
12 |
12 |
$420.00 |