| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,180 |
2,170 |
$140K |
| D1120 |
Prophylaxis - child |
3,291 |
3,271 |
$131K |
| D0120 |
Periodic oral evaluation - established patient |
1,958 |
1,944 |
$107K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,460 |
729 |
$94K |
| D1351 |
Sealant - per tooth |
1,846 |
495 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,972 |
2,956 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
489 |
287 |
$39K |
| D9430 |
|
1,207 |
1,120 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,153 |
3,717 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,299 |
1,288 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,754 |
1,747 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
524 |
488 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
374 |
371 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
167 |
95 |
$9K |
| D1310 |
|
196 |
195 |
$8K |
| D1110 |
Prophylaxis - adult |
97 |
97 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
37 |
$3K |
| D0350 |
|
251 |
125 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
141 |
$2K |
| D9993 |
|
61 |
61 |
$1K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$1K |
| D0340 |
|
12 |
12 |
$600.00 |
| D0603 |
|
28 |
28 |
$390.00 |
| D0601 |
|
13 |
13 |
$191.25 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$185.50 |