| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,231 |
4,166 |
$156K |
| D1110 |
Prophylaxis - adult |
2,122 |
2,089 |
$152K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,511 |
4,451 |
$100K |
| D1120 |
Prophylaxis - child |
2,387 |
2,355 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,355 |
848 |
$73K |
| D0220 |
Intraoral - periapical first radiographic image |
4,017 |
3,910 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,874 |
3,378 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,794 |
1,776 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
661 |
408 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
572 |
563 |
$28K |
| D4910 |
|
170 |
170 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
420 |
413 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
271 |
200 |
$18K |
| D9430 |
|
544 |
479 |
$15K |
| D0272 |
Bitewings - two radiographic images |
985 |
979 |
$12K |
| D1999 |
|
949 |
919 |
$9K |
| D0170 |
|
37 |
27 |
$2K |
| D0999 |
Unspecified diagnostic procedure, by report |
27 |
27 |
$2K |
| D0160 |
|
37 |
29 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$1K |
| D1351 |
Sealant - per tooth |
49 |
12 |
$704.00 |
| D0602 |
|
162 |
162 |
$155.00 |
| D0603 |
|
126 |
126 |
$99.00 |
| D0601 |
|
12 |
12 |
$12.00 |
| D1330 |
|
1,008 |
1,005 |
$0.00 |
| D9993 |
|
237 |
237 |
$0.00 |