| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,331 |
1,330 |
$101K |
| D1110 |
Prophylaxis - adult |
746 |
745 |
$66K |
| D1120 |
Prophylaxis - child |
910 |
903 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,995 |
1,769 |
$42K |
| D4341 |
|
574 |
149 |
$40K |
| D8670 |
Periodic orthodontic treatment visit |
107 |
107 |
$31K |
| D9110 |
|
473 |
446 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,946 |
1,876 |
$23K |
| D4910 |
|
257 |
256 |
$20K |
| D9430 |
|
602 |
592 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,194 |
1,192 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
235 |
234 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
890 |
883 |
$13K |
| D0274 |
Bitewings - four radiographic images |
559 |
557 |
$12K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
18 |
12 |
$9K |
| D1351 |
Sealant - per tooth |
178 |
55 |
$6K |
| D0350 |
|
281 |
243 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
31 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
32 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$1K |
| D0340 |
|
24 |
24 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$560.00 |