| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,697 |
3,669 |
$267K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,042 |
1,756 |
$203K |
| D1120 |
Prophylaxis - child |
4,348 |
4,323 |
$198K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
353 |
290 |
$163K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,426 |
2,417 |
$161K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24,041 |
5,209 |
$99K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,762 |
1,160 |
$95K |
| D0274 |
Bitewings - four radiographic images |
3,453 |
3,437 |
$74K |
| D1110 |
Prophylaxis - adult |
785 |
785 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,070 |
5,043 |
$67K |
| D0210 |
Intraoral - complete series of radiographic images |
1,126 |
1,121 |
$54K |
| D1351 |
Sealant - per tooth |
1,677 |
547 |
$52K |
| D0350 |
|
4,059 |
1,856 |
$39K |
| D4341 |
|
381 |
140 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
299 |
223 |
$24K |
| D2954 |
|
202 |
166 |
$21K |
| D9430 |
|
618 |
607 |
$20K |
| D1310 |
|
297 |
297 |
$12K |
| D9993 |
|
229 |
229 |
$10K |
| D0272 |
Bitewings - two radiographic images |
762 |
761 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
119 |
79 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
52 |
39 |
$6K |
| D3320 |
|
13 |
12 |
$5K |
| D4910 |
|
51 |
51 |
$4K |
| D1206 |
Topical application of fluoride varnish |
122 |
122 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
59 |
$714.05 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$455.00 |
| D0601 |
|
17 |
17 |
$255.00 |
| D1320 |
|
23 |
23 |
$235.00 |
| D0270 |
|
30 |
29 |
$150.00 |