| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,358 |
1,351 |
$60K |
| D1110 |
Prophylaxis - adult |
804 |
801 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,928 |
1,909 |
$23K |
| D1120 |
Prophylaxis - child |
1,176 |
1,142 |
$23K |
| D9999 |
Unspecified adjunctive procedure, by report |
158 |
157 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
801 |
799 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
823 |
796 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,834 |
1,542 |
$12K |
| D4341 |
|
266 |
90 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
133 |
67 |
$9K |
| D1351 |
Sealant - per tooth |
372 |
115 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
121 |
$6K |
| D4910 |
|
85 |
85 |
$5K |
| D2140 |
|
91 |
51 |
$5K |
| D0274 |
Bitewings - four radiographic images |
395 |
393 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,153 |
1,019 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
80 |
44 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
53 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
67 |
37 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
30 |
14 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
315 |
308 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
13 |
$2K |
| D0350 |
|
379 |
245 |
$2K |
| D9430 |
|
101 |
97 |
$2K |
| D0272 |
Bitewings - two radiographic images |
265 |
262 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
26 |
$1K |
| D2160 |
|
14 |
12 |
$1K |
| D1310 |
|
12 |
12 |
$506.00 |
| D1330 |
|
1,517 |
1,475 |
$0.00 |