| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
10,585 |
10,550 |
$375K |
| D1120 |
Prophylaxis - child |
11,118 |
11,062 |
$359K |
| D1208 |
Topical application of fluoride, excluding varnish |
17,281 |
17,192 |
$320K |
| D1351 |
Sealant - per tooth |
11,546 |
3,023 |
$281K |
| D1110 |
Prophylaxis - adult |
6,202 |
6,170 |
$262K |
| D0274 |
Bitewings - four radiographic images |
8,585 |
8,538 |
$256K |
| D0220 |
Intraoral - periapical first radiographic image |
20,560 |
20,324 |
$236K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,952 |
878 |
$222K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,861 |
17,925 |
$199K |
| D0330 |
Panoramic radiographic image |
5,593 |
5,568 |
$170K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,245 |
1,363 |
$169K |
| D0120 |
Periodic oral evaluation - established patient |
6,883 |
6,839 |
$158K |
| D0272 |
Bitewings - two radiographic images |
6,887 |
6,847 |
$143K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,997 |
737 |
$135K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,260 |
1,220 |
$128K |
| D0140 |
Limited oral evaluation - problem focused |
3,226 |
3,200 |
$97K |
| D0210 |
Intraoral - complete series of radiographic images |
1,407 |
820 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
715 |
668 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
153 |
92 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
99 |
77 |
$9K |
| D2140 |
|
80 |
27 |
$5K |
| D4341 |
|
36 |
13 |
$4K |
| D4346 |
|
12 |
12 |
$2K |
| D0270 |
|
71 |
71 |
$727.21 |