| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,318 |
3,318 |
$218K |
| D1110 |
Prophylaxis - adult |
1,883 |
1,883 |
$168K |
| D0210 |
Intraoral - complete series of radiographic images |
2,785 |
2,785 |
$131K |
| D0350 |
|
13,182 |
3,301 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
1,135 |
1,135 |
$70K |
| D1206 |
Topical application of fluoride varnish |
3,437 |
3,436 |
$53K |
| D1120 |
Prophylaxis - child |
1,414 |
1,411 |
$52K |
| D1351 |
Sealant - per tooth |
1,577 |
399 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,753 |
1,967 |
$39K |
| D0330 |
Panoramic radiographic image |
861 |
859 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
465 |
192 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
261 |
143 |
$17K |
| D9430 |
|
527 |
514 |
$17K |
| D0274 |
Bitewings - four radiographic images |
813 |
813 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
956 |
945 |
$11K |
| D9993 |
|
90 |
90 |
$6K |
| D1310 |
|
123 |
122 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
34 |
12 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
95 |
$1K |
| D0270 |
|
12 |
12 |
$60.00 |
| D1999 |
|
35 |
32 |
$0.00 |