| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,997 |
5,995 |
$168K |
| D1120 |
Prophylaxis - child |
4,014 |
4,013 |
$141K |
| D1110 |
Prophylaxis - adult |
3,147 |
3,146 |
$111K |
| D1206 |
Topical application of fluoride varnish |
4,480 |
4,477 |
$77K |
| D1351 |
Sealant - per tooth |
5,024 |
668 |
$65K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,201 |
645 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,211 |
785 |
$52K |
| D0330 |
Panoramic radiographic image |
2,001 |
2,000 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,127 |
634 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,425 |
1,425 |
$40K |
| D0251 |
|
3,882 |
3,881 |
$37K |
| D2740 |
Crown - porcelain/ceramic |
60 |
54 |
$23K |
| D2950 |
|
335 |
288 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
772 |
761 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,342 |
1,342 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
379 |
378 |
$11K |
| D0603 |
|
1,013 |
1,013 |
$10K |
| D2335 |
|
135 |
74 |
$9K |
| D0601 |
|
899 |
899 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
115 |
$7K |
| D0602 |
|
632 |
632 |
$6K |
| D9920 |
|
261 |
257 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
769 |
738 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
162 |
154 |
$3K |
| D2330 |
|
40 |
27 |
$2K |
| D4341 |
|
25 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$920.00 |
| D0272 |
Bitewings - two radiographic images |
21 |
21 |
$147.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$102.00 |
| D0270 |
|
25 |
24 |
$75.00 |