| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,919 |
5,861 |
$207K |
| D0120 |
Periodic oral evaluation - established patient |
7,119 |
7,072 |
$111K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,940 |
4,908 |
$93K |
| D1120 |
Prophylaxis - child |
2,890 |
2,876 |
$88K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
1,695 |
268 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,791 |
2,732 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,145 |
606 |
$71K |
| D0274 |
Bitewings - four radiographic images |
3,262 |
3,229 |
$65K |
| D0210 |
Intraoral - complete series of radiographic images |
1,387 |
1,201 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
4,122 |
3,851 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,535 |
1,527 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,036 |
2,148 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
352 |
144 |
$27K |
| D9920 |
|
309 |
279 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
981 |
877 |
$19K |
| D0330 |
Panoramic radiographic image |
379 |
377 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
214 |
128 |
$14K |
| D0272 |
Bitewings - two radiographic images |
637 |
634 |
$12K |
| D9222 |
|
270 |
259 |
$12K |
| D2750 |
|
17 |
12 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
138 |
73 |
$10K |
| D9612 |
|
282 |
271 |
$8K |
| D1351 |
Sealant - per tooth |
227 |
65 |
$7K |
| D9630 |
|
250 |
250 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
25 |
14 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
121 |
112 |
$4K |
| D1354 |
|
181 |
68 |
$2K |
| D3120 |
|
78 |
47 |
$1K |
| D9310 |
|
79 |
76 |
$998.28 |
| S0504 |
Single vision prescription lens (safety, athletic, or sunglass), per lens |
67 |
67 |
$945.00 |
| D9110 |
|
18 |
15 |
$871.74 |
| S0516 |
Safety eyeglass frames |
67 |
67 |
$569.50 |
| D9994 |
|
74 |
74 |
$519.92 |
| D0190 |
|
12 |
12 |
$0.00 |
| D4910 |
|
67 |
67 |
$0.00 |
| D2950 |
|
114 |
93 |
$0.00 |
| D2394 |
|
25 |
19 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
113 |
85 |
$0.00 |
| D9219 |
|
67 |
64 |
$0.00 |
| D8670 |
Periodic orthodontic treatment visit |
13 |
13 |
$0.00 |
| D4342 |
|
30 |
12 |
$0.00 |