| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,056 |
4,048 |
$236K |
| D1120 |
Prophylaxis - child |
4,455 |
4,435 |
$167K |
| D0230 |
Intraoral - periapical each additional radiographic image |
33,988 |
6,479 |
$138K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,566 |
1,561 |
$90K |
| D1110 |
Prophylaxis - adult |
1,017 |
1,013 |
$87K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,715 |
5,692 |
$66K |
| D0274 |
Bitewings - four radiographic images |
2,017 |
2,012 |
$41K |
| D0272 |
Bitewings - two radiographic images |
2,727 |
2,719 |
$32K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
394 |
236 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,118 |
1,953 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
371 |
207 |
$25K |
| D0350 |
|
2,041 |
857 |
$17K |
| D1351 |
Sealant - per tooth |
638 |
161 |
$16K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
33 |
30 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
226 |
123 |
$12K |
| D4341 |
|
152 |
40 |
$10K |
| D4910 |
|
95 |
95 |
$7K |
| D7240 |
Removal of impacted tooth - completely bony |
26 |
12 |
$6K |
| D1310 |
|
55 |
55 |
$2K |
| D1206 |
Topical application of fluoride varnish |
143 |
142 |
$2K |
| D9430 |
|
64 |
58 |
$2K |
| D2160 |
|
14 |
12 |
$1K |
| D9993 |
|
41 |
41 |
$975.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$420.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$38.64 |