| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,133 |
3,118 |
$179K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,757 |
2,749 |
$171K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
208 |
174 |
$99K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,764 |
996 |
$95K |
| D1120 |
Prophylaxis - child |
2,593 |
2,577 |
$92K |
| D9430 |
|
2,680 |
2,477 |
$85K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,637 |
6,247 |
$82K |
| D0350 |
|
6,104 |
3,805 |
$79K |
| D0210 |
Intraoral - complete series of radiographic images |
1,666 |
1,665 |
$78K |
| D1110 |
Prophylaxis - adult |
891 |
884 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,141 |
657 |
$76K |
| D0274 |
Bitewings - four radiographic images |
3,345 |
3,323 |
$67K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
737 |
434 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
2,846 |
2,594 |
$34K |
| D7240 |
Removal of impacted tooth - completely bony |
105 |
49 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,166 |
2,155 |
$21K |
| D1351 |
Sealant - per tooth |
727 |
210 |
$20K |
| D2140 |
|
200 |
135 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
80 |
52 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
88 |
62 |
$7K |
| D7230 |
|
29 |
12 |
$5K |
| D2330 |
|
47 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
103 |
103 |
$3K |
| D2954 |
|
27 |
24 |
$3K |
| D4341 |
|
27 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
108 |
108 |
$1K |
| D2160 |
|
15 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$440.00 |