| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,136 |
4,106 |
$85K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,765 |
936 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,587 |
958 |
$62K |
| D1120 |
Prophylaxis - child |
3,104 |
3,078 |
$54K |
| D1110 |
Prophylaxis - adult |
2,131 |
2,115 |
$41K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
93 |
76 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,976 |
2,949 |
$27K |
| D0274 |
Bitewings - four radiographic images |
2,515 |
2,490 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
723 |
721 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
4,735 |
4,577 |
$18K |
| D1351 |
Sealant - per tooth |
1,625 |
235 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
956 |
887 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,965 |
3,590 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
628 |
608 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
381 |
381 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
208 |
149 |
$7K |
| D1206 |
Topical application of fluoride varnish |
409 |
409 |
$6K |
| D0272 |
Bitewings - two radiographic images |
699 |
697 |
$3K |
| D9920 |
|
174 |
174 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
53 |
$3K |
| D2954 |
|
36 |
29 |
$2K |
| D0601 |
|
164 |
164 |
$2K |
| D0603 |
|
148 |
148 |
$1K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$1K |
| D9310 |
|
68 |
68 |
$1K |
| D0340 |
|
68 |
68 |
$1K |
| D2332 |
|
16 |
12 |
$792.00 |
| D0270 |
|
59 |
59 |
$177.00 |
| D0350 |
|
46 |
46 |
$46.00 |
| D1999 |
|
110 |
105 |
$0.00 |