| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
7,099 |
7,099 |
$526K |
| D0120 |
Periodic oral evaluation - established patient |
6,111 |
6,111 |
$227K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,456 |
1,331 |
$204K |
| D0274 |
Bitewings - four radiographic images |
3,039 |
3,039 |
$113K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
879 |
829 |
$80K |
| D0210 |
Intraoral - complete series of radiographic images |
1,736 |
1,727 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,867 |
1,866 |
$54K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
329 |
306 |
$52K |
| D2740 |
Crown - porcelain/ceramic |
43 |
42 |
$32K |
| D0330 |
Panoramic radiographic image |
662 |
662 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,299 |
1,277 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,301 |
1,300 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
804 |
788 |
$13K |
| D1120 |
Prophylaxis - child |
240 |
239 |
$12K |
| D2394 |
|
59 |
57 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
52 |
52 |
$9K |
| D2331 |
|
47 |
46 |
$7K |
| D9310 |
|
114 |
114 |
$6K |
| D1351 |
Sealant - per tooth |
25 |
25 |
$5K |
| D2332 |
|
27 |
26 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
24 |
$3K |
| D2954 |
|
13 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
116 |
116 |
$2K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
15 |
15 |
$2K |
| D9222 |
|
15 |
15 |
$949.00 |
| D9110 |
|
25 |
25 |
$942.50 |
| D9995 |
|
12 |
12 |
$281.76 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$265.20 |
| D0190 |
|
12 |
12 |
$55.00 |
| D1999 |
|
192 |
172 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$0.00 |