| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,219 |
2,214 |
$145K |
| D0210 |
Intraoral - complete series of radiographic images |
1,202 |
1,200 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
827 |
419 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
889 |
427 |
$48K |
| D1120 |
Prophylaxis - child |
1,134 |
1,122 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,603 |
1,299 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
550 |
550 |
$34K |
| D2740 |
Crown - porcelain/ceramic |
50 |
38 |
$24K |
| D4341 |
|
246 |
67 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
849 |
840 |
$11K |
| D1351 |
Sealant - per tooth |
349 |
94 |
$10K |
| D0272 |
Bitewings - two radiographic images |
545 |
545 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
54 |
37 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
94 |
92 |
$4K |
| D8670 |
Periodic orthodontic treatment visit |
12 |
12 |
$4K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
28 |
14 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$525.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$172.80 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |