| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,739 |
4,716 |
$297K |
| D0120 |
Periodic oral evaluation - established patient |
4,713 |
4,697 |
$245K |
| D0210 |
Intraoral - complete series of radiographic images |
3,546 |
3,524 |
$166K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,921 |
5,889 |
$118K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
846 |
477 |
$100K |
| D1120 |
Prophylaxis - child |
2,381 |
2,370 |
$89K |
| D4341 |
|
1,259 |
520 |
$88K |
| D0274 |
Bitewings - four radiographic images |
3,798 |
3,760 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,098 |
737 |
$74K |
| D1110 |
Prophylaxis - adult |
696 |
695 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,502 |
3,488 |
$43K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
615 |
405 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
423 |
291 |
$23K |
| D4910 |
|
302 |
300 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
238 |
69 |
$13K |
| D1351 |
Sealant - per tooth |
611 |
136 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
254 |
226 |
$10K |
| D0350 |
|
732 |
460 |
$7K |
| D0330 |
Panoramic radiographic image |
695 |
695 |
$7K |
| D4342 |
|
164 |
73 |
$7K |
| D9910 |
|
116 |
116 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
175 |
$6K |
| D0272 |
Bitewings - two radiographic images |
452 |
451 |
$5K |
| D9430 |
|
113 |
113 |
$4K |
| D2331 |
|
34 |
24 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
16 |
$2K |
| D1206 |
Topical application of fluoride varnish |
135 |
134 |
$1K |
| D2140 |
|
16 |
12 |
$873.60 |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
61 |
$732.00 |
| D0270 |
|
40 |
40 |
$190.00 |