| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,958 |
2,953 |
$181K |
| D0120 |
Periodic oral evaluation - established patient |
3,144 |
3,137 |
$146K |
| D0210 |
Intraoral - complete series of radiographic images |
2,525 |
2,524 |
$118K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,057 |
3,896 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,013 |
500 |
$68K |
| D1120 |
Prophylaxis - child |
1,880 |
1,878 |
$61K |
| D1110 |
Prophylaxis - adult |
787 |
786 |
$60K |
| D0274 |
Bitewings - four radiographic images |
2,688 |
2,673 |
$56K |
| D7140 |
Extraction, erupted tooth or exposed root |
851 |
295 |
$48K |
| D4341 |
|
677 |
246 |
$46K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
583 |
314 |
$39K |
| D8670 |
Periodic orthodontic treatment visit |
117 |
116 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
411 |
216 |
$33K |
| D1351 |
Sealant - per tooth |
1,122 |
336 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,477 |
1,476 |
$21K |
| D2160 |
|
232 |
138 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,200 |
1,198 |
$11K |
| D9910 |
|
120 |
118 |
$6K |
| D0350 |
|
631 |
351 |
$6K |
| D4910 |
|
78 |
78 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
62 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
147 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
24 |
$4K |
| D0272 |
Bitewings - two radiographic images |
258 |
258 |
$3K |
| D0330 |
Panoramic radiographic image |
123 |
123 |
$2K |
| D2140 |
|
21 |
14 |
$1K |
| D9430 |
|
15 |
15 |
$480.00 |
| D0270 |
|
12 |
12 |
$55.00 |
| D1330 |
|
143 |
143 |
$0.00 |