| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,474 |
5,448 |
$341K |
| D0120 |
Periodic oral evaluation - established patient |
5,334 |
5,301 |
$283K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,028 |
932 |
$233K |
| D1351 |
Sealant - per tooth |
7,253 |
1,435 |
$197K |
| D1120 |
Prophylaxis - child |
4,795 |
4,723 |
$174K |
| D1110 |
Prophylaxis - adult |
1,838 |
1,820 |
$150K |
| D0210 |
Intraoral - complete series of radiographic images |
3,199 |
3,175 |
$146K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,061 |
1,143 |
$135K |
| D2740 |
Crown - porcelain/ceramic |
280 |
184 |
$131K |
| D0230 |
Intraoral - periapical each additional radiographic image |
30,983 |
8,544 |
$128K |
| D0274 |
Bitewings - four radiographic images |
4,982 |
4,888 |
$101K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,559 |
7,461 |
$90K |
| D9430 |
|
1,241 |
1,211 |
$40K |
| D4341 |
|
514 |
150 |
$35K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
166 |
115 |
$27K |
| D4910 |
|
216 |
212 |
$16K |
| D9222 |
|
115 |
114 |
$12K |
| D2954 |
|
105 |
72 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
84 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
147 |
125 |
$6K |
| D7230 |
|
23 |
12 |
$4K |
| D0272 |
Bitewings - two radiographic images |
363 |
355 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
28 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
14 |
$3K |
| D4342 |
|
53 |
15 |
$2K |
| D9241 |
|
26 |
26 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
112 |
111 |
$1K |
| D9910 |
|
36 |
35 |
$827.75 |
| D9242 |
|
26 |
26 |
$531.00 |
| D0350 |
|
21 |
12 |
$201.60 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$120.00 |
| D0270 |
|
13 |
12 |
$60.00 |
| D0140 |
Limited oral evaluation - problem focused |
50 |
48 |
$0.00 |
| D7953 |
|
48 |
36 |
$0.00 |
| D4381 |
|
29 |
20 |
$0.00 |