| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,274 |
1,243 |
$70K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
335 |
157 |
$40K |
| D9430 |
|
1,296 |
1,236 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
524 |
521 |
$29K |
| D1120 |
Prophylaxis - child |
675 |
666 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,134 |
1,113 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
389 |
240 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
266 |
183 |
$16K |
| D1110 |
Prophylaxis - adult |
192 |
192 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
343 |
336 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
141 |
64 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,477 |
1,822 |
$9K |
| D0272 |
Bitewings - two radiographic images |
576 |
570 |
$5K |
| D4341 |
|
29 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
43 |
12 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
15 |
15 |
$900.00 |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$828.00 |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
105 |
$733.00 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$725.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
15 |
15 |
$600.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$420.00 |
| D0270 |
|
59 |
57 |
$285.00 |
| D9993 |
|
29 |
29 |
$195.00 |
| D1310 |
|
29 |
29 |
$138.00 |
| D0601 |
|
19 |
13 |
$34.00 |
| D1330 |
|
1,101 |
1,091 |
$0.00 |
| D1999 |
|
20 |
17 |
$0.00 |