| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,726 |
4,722 |
$311K |
| D1110 |
Prophylaxis - adult |
3,467 |
3,464 |
$310K |
| D1351 |
Sealant - per tooth |
8,228 |
1,673 |
$264K |
| D0120 |
Periodic oral evaluation - established patient |
3,021 |
3,017 |
$228K |
| D1120 |
Prophylaxis - child |
4,132 |
4,131 |
$190K |
| D0210 |
Intraoral - complete series of radiographic images |
3,972 |
3,970 |
$189K |
| D1206 |
Topical application of fluoride varnish |
7,683 |
7,680 |
$121K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28,558 |
4,551 |
$116K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,656 |
987 |
$110K |
| D9430 |
|
2,358 |
2,076 |
$75K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
561 |
311 |
$66K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
597 |
409 |
$47K |
| D4341 |
|
670 |
182 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
3,618 |
3,611 |
$43K |
| D2335 |
|
299 |
98 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
594 |
283 |
$32K |
| D0330 |
Panoramic radiographic image |
1,060 |
1,057 |
$31K |
| D1310 |
|
366 |
366 |
$16K |
| D2332 |
|
100 |
52 |
$9K |
| D0350 |
|
845 |
367 |
$7K |
| D9993 |
|
101 |
101 |
$5K |
| D2394 |
|
60 |
46 |
$5K |
| D4910 |
|
52 |
52 |
$4K |
| D4342 |
|
92 |
27 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
25 |
$3K |
| D2330 |
|
36 |
24 |
$3K |
| D0274 |
Bitewings - four radiographic images |
28 |
27 |
$561.60 |
| D0603 |
|
40 |
40 |
$555.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$158.00 |
| D1999 |
|
74 |
61 |
$138.00 |