| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,980 |
2,941 |
$184K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,703 |
1,266 |
$175K |
| D0120 |
Periodic oral evaluation - established patient |
2,089 |
2,082 |
$132K |
| D0210 |
Intraoral - complete series of radiographic images |
2,457 |
2,430 |
$114K |
| D1120 |
Prophylaxis - child |
2,532 |
2,510 |
$98K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,731 |
861 |
$92K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,630 |
3,084 |
$59K |
| D1110 |
Prophylaxis - adult |
691 |
688 |
$58K |
| D0274 |
Bitewings - four radiographic images |
2,070 |
2,052 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,197 |
3,173 |
$38K |
| D0350 |
|
3,306 |
1,314 |
$32K |
| D9430 |
|
943 |
879 |
$29K |
| D1351 |
Sealant - per tooth |
722 |
200 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
168 |
101 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
209 |
143 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
113 |
49 |
$6K |
| D4910 |
|
73 |
73 |
$5K |
| D4341 |
|
47 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
121 |
121 |
$3K |
| D0340 |
|
35 |
35 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
141 |
$2K |
| D1320 |
|
88 |
85 |
$780.00 |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$365.00 |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$246.00 |
| D1999 |
|
111 |
109 |
$100.00 |
| D1310 |
|
111 |
109 |
$0.00 |
| D1330 |
|
112 |
110 |
$0.00 |