| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,265 |
3,237 |
$247K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,807 |
2,802 |
$186K |
| D1120 |
Prophylaxis - child |
4,048 |
4,024 |
$182K |
| D1110 |
Prophylaxis - adult |
1,552 |
1,545 |
$138K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19,420 |
4,845 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,445 |
980 |
$97K |
| D0210 |
Intraoral - complete series of radiographic images |
1,743 |
1,737 |
$83K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,145 |
5,115 |
$69K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
136 |
114 |
$64K |
| D0274 |
Bitewings - four radiographic images |
2,802 |
2,783 |
$60K |
| D1351 |
Sealant - per tooth |
1,555 |
378 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
587 |
437 |
$32K |
| D1310 |
|
429 |
427 |
$19K |
| D0350 |
|
1,784 |
1,046 |
$19K |
| D9430 |
|
561 |
548 |
$18K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
145 |
76 |
$17K |
| D0272 |
Bitewings - two radiographic images |
895 |
894 |
$11K |
| D9993 |
|
180 |
180 |
$10K |
| D1206 |
Topical application of fluoride varnish |
360 |
360 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
538 |
529 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
48 |
$5K |
| D0601 |
|
40 |
40 |
$600.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$459.00 |
| D0270 |
|
53 |
53 |
$265.00 |
| D0602 |
|
12 |
12 |
$180.00 |