| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,500 |
1,477 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
1,374 |
1,337 |
$89K |
| D1110 |
Prophylaxis - adult |
972 |
971 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,169 |
3,002 |
$67K |
| D1120 |
Prophylaxis - child |
1,556 |
1,549 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,264 |
2,255 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,690 |
2,687 |
$35K |
| D8670 |
Periodic orthodontic treatment visit |
86 |
86 |
$25K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
12 |
12 |
$13K |
| D0330 |
Panoramic radiographic image |
394 |
394 |
$12K |
| D4910 |
|
137 |
137 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
71 |
37 |
$8K |
| D0340 |
|
155 |
155 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
76 |
$7K |
| D1351 |
Sealant - per tooth |
209 |
47 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
25 |
$3K |
| D4341 |
|
41 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$455.00 |
| D9430 |
|
13 |
13 |
$416.00 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
29 |
$360.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$168.00 |