| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
469 |
412 |
$278K |
| D0120 |
Periodic oral evaluation - established patient |
5,609 |
5,592 |
$214K |
| D1110 |
Prophylaxis - adult |
4,843 |
4,822 |
$213K |
| D9920 |
|
6,014 |
5,050 |
$137K |
| D1120 |
Prophylaxis - child |
2,685 |
2,676 |
$121K |
| D0140 |
Limited oral evaluation - problem focused |
2,353 |
2,169 |
$101K |
| D1206 |
Topical application of fluoride varnish |
3,622 |
3,605 |
$100K |
| D0210 |
Intraoral - complete series of radiographic images |
1,717 |
1,711 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,718 |
1,707 |
$66K |
| D0274 |
Bitewings - four radiographic images |
2,898 |
2,890 |
$44K |
| D2954 |
|
414 |
353 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
6,338 |
6,022 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,355 |
5,042 |
$24K |
| D0273 |
|
1,325 |
1,320 |
$15K |
| D0601 |
|
1,052 |
1,044 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
83 |
44 |
$7K |
| D0603 |
|
395 |
395 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
267 |
266 |
$4K |
| D0170 |
|
43 |
41 |
$2K |
| D1351 |
Sealant - per tooth |
71 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$1K |
| D0602 |
|
96 |
96 |
$998.00 |
| D0240 |
|
58 |
38 |
$792.00 |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$477.25 |
| D9210 |
|
168 |
152 |
$286.00 |
| D0190 |
|
32 |
32 |
$220.00 |
| D2799 |
|
312 |
264 |
$0.00 |
| D9215 |
|
1,305 |
1,059 |
$0.00 |