| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
907 |
903 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
724 |
356 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
567 |
563 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
776 |
598 |
$9K |
| D1110 |
Prophylaxis - adult |
767 |
764 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
852 |
832 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
139 |
93 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
304 |
268 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
518 |
375 |
$4K |
| D1206 |
Topical application of fluoride varnish |
1,130 |
1,124 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,793 |
1,764 |
$4K |
| D1120 |
Prophylaxis - child |
542 |
538 |
$4K |
| D0274 |
Bitewings - four radiographic images |
950 |
946 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
1,166 |
1,156 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,683 |
1,251 |
$3K |
| D4341 |
|
55 |
26 |
$900.00 |
| D0272 |
Bitewings - two radiographic images |
98 |
98 |
$300.00 |
| D2394 |
|
40 |
40 |
$291.00 |
| D4910 |
|
28 |
28 |
$210.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
90 |
$190.00 |
| D0270 |
|
150 |
145 |
$165.00 |
| D1330 |
|
1,586 |
1,562 |
$100.00 |
| D9310 |
|
12 |
12 |
$90.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
35 |
$26.00 |
| D9986 |
|
263 |
259 |
$0.00 |
| D1310 |
|
88 |
88 |
$0.00 |
| D3120 |
|
30 |
28 |
$0.00 |
| D1351 |
Sealant - per tooth |
32 |
12 |
$0.00 |