| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,050 |
1,945 |
$89K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
609 |
340 |
$62K |
| D1110 |
Prophylaxis - adult |
1,381 |
1,343 |
$50K |
| D1120 |
Prophylaxis - child |
1,454 |
1,382 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
610 |
579 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,370 |
1,345 |
$35K |
| D1206 |
Topical application of fluoride varnish |
2,346 |
2,259 |
$35K |
| D1351 |
Sealant - per tooth |
1,288 |
290 |
$34K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
234 |
51 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,257 |
1,189 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,972 |
511 |
$16K |
| D0274 |
Bitewings - four radiographic images |
557 |
543 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
114 |
$13K |
| D0272 |
Bitewings - two radiographic images |
567 |
531 |
$9K |
| D0330 |
Panoramic radiographic image |
259 |
252 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
221 |
214 |
$7K |
| D0240 |
|
460 |
204 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
121 |
106 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
13 |
$1K |
| D4355 |
|
12 |
12 |
$887.64 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
37 |
$651.91 |
| D0351 |
|
63 |
61 |
$0.00 |
| D0350 |
|
142 |
113 |
$0.00 |