| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,241 |
3,237 |
$48K |
| D0140 |
Limited oral evaluation - problem focused |
2,752 |
2,729 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,511 |
1,508 |
$34K |
| D1120 |
Prophylaxis - child |
2,377 |
2,374 |
$33K |
| D1110 |
Prophylaxis - adult |
1,226 |
1,225 |
$20K |
| D1351 |
Sealant - per tooth |
2,037 |
528 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,894 |
1,893 |
$19K |
| D0274 |
Bitewings - four radiographic images |
2,138 |
2,132 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
3,110 |
3,090 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
319 |
275 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
364 |
364 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
305 |
268 |
$9K |
| D4346 |
|
210 |
210 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,703 |
1,392 |
$6K |
| D1206 |
Topical application of fluoride varnish |
360 |
360 |
$5K |
| D0330 |
Panoramic radiographic image |
326 |
326 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
116 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
89 |
80 |
$3K |
| D0272 |
Bitewings - two radiographic images |
676 |
676 |
$3K |
| D2140 |
|
93 |
84 |
$3K |
| D2331 |
|
26 |
24 |
$1K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
45 |
40 |
$937.86 |
| D2330 |
|
18 |
14 |
$639.00 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
13 |
12 |
$282.00 |
| D1999 |
|
147 |
100 |
$0.00 |
| D0431 |
|
319 |
317 |
$0.00 |