| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,032 |
910 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,914 |
1,636 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,676 |
1,510 |
$11K |
| D1120 |
Prophylaxis - child |
1,115 |
989 |
$9K |
| D9999 |
Unspecified adjunctive procedure, by report |
63 |
63 |
$7K |
| D1351 |
Sealant - per tooth |
308 |
85 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,068 |
2,160 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
667 |
585 |
$5K |
| D1110 |
Prophylaxis - adult |
415 |
348 |
$5K |
| D9430 |
|
1,024 |
816 |
$4K |
| D0274 |
Bitewings - four radiographic images |
1,318 |
1,123 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
2,117 |
1,733 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
55 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
137 |
45 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
81 |
40 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
40 |
$964.60 |
| D0330 |
Panoramic radiographic image |
102 |
101 |
$414.00 |
| D0272 |
Bitewings - two radiographic images |
289 |
274 |
$362.00 |
| D4341 |
|
36 |
13 |
$250.00 |
| D1320 |
|
20 |
20 |
$127.50 |
| D1999 |
|
116 |
81 |
$40.00 |
| D0270 |
|
12 |
12 |
$22.00 |
| D9910 |
|
47 |
20 |
$0.00 |
| D1330 |
|
1,121 |
1,016 |
$0.00 |