| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,203 |
4,094 |
$222K |
| D1120 |
Prophylaxis - child |
2,675 |
2,647 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
5,467 |
5,346 |
$128K |
| D0274 |
Bitewings - four radiographic images |
2,848 |
2,778 |
$95K |
| D1206 |
Topical application of fluoride varnish |
3,779 |
3,742 |
$93K |
| D8670 |
Periodic orthodontic treatment visit |
281 |
274 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
524 |
333 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
622 |
399 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
977 |
922 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
647 |
629 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,976 |
1,865 |
$27K |
| D0330 |
Panoramic radiographic image |
440 |
433 |
$23K |
| D1351 |
Sealant - per tooth |
508 |
134 |
$19K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
219 |
97 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
958 |
795 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
16 |
12 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
121 |
44 |
$8K |
| D0272 |
Bitewings - two radiographic images |
150 |
148 |
$4K |
| D2160 |
|
39 |
27 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
47 |
44 |
$3K |
| D2140 |
|
40 |
18 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$377.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
13 |
$273.00 |
| D1999 |
|
1,845 |
1,615 |
$0.00 |
| D9995 |
|
17 |
16 |
$0.00 |