| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,079 |
1,049 |
$6K |
| D1120 |
Prophylaxis - child |
1,200 |
1,182 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,526 |
3,006 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,021 |
977 |
$4K |
| D1206 |
Topical application of fluoride varnish |
1,497 |
1,466 |
$3K |
| D0274 |
Bitewings - four radiographic images |
882 |
855 |
$669.60 |
| D0272 |
Bitewings - two radiographic images |
561 |
510 |
$330.00 |
| D9430 |
|
2,362 |
1,975 |
$308.00 |
| D0220 |
Intraoral - periapical first radiographic image |
666 |
558 |
$168.00 |
| D1330 |
|
1,957 |
1,845 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
357 |
299 |
$0.00 |
| D0601 |
|
457 |
452 |
$0.00 |
| D7230 |
|
363 |
262 |
$0.00 |
| D1310 |
|
1,278 |
1,259 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
706 |
501 |
$0.00 |
| D0603 |
|
398 |
394 |
$0.00 |
| D1351 |
Sealant - per tooth |
696 |
222 |
$0.00 |
| D0602 |
|
219 |
219 |
$0.00 |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
137 |
116 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
609 |
379 |
$0.00 |
| D7240 |
Removal of impacted tooth - completely bony |
68 |
54 |
$0.00 |
| D7953 |
|
19 |
13 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
385 |
228 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
149 |
116 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
15 |
$0.00 |
| D4266 |
|
19 |
13 |
$0.00 |
| D0350 |
|
246 |
200 |
$0.00 |
| D9993 |
|
1,275 |
1,258 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,395 |
931 |
$0.00 |
| D0270 |
|
1,144 |
923 |
$0.00 |
| D0330 |
Panoramic radiographic image |
828 |
691 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
236 |
187 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
54 |
39 |
$0.00 |
| D1510 |
|
24 |
13 |
$0.00 |
| D9110 |
|
13 |
13 |
$0.00 |
| D2140 |
|
24 |
14 |
$0.00 |