| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,158 |
3,143 |
$193K |
| D1110 |
Prophylaxis - adult |
1,689 |
1,681 |
$146K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,868 |
1,054 |
$125K |
| D1120 |
Prophylaxis - child |
2,504 |
2,492 |
$96K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,539 |
1,534 |
$95K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,523 |
679 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,610 |
3,413 |
$76K |
| D0210 |
Intraoral - complete series of radiographic images |
1,550 |
1,546 |
$72K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
136 |
100 |
$64K |
| D0274 |
Bitewings - four radiographic images |
2,377 |
2,364 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,159 |
4,143 |
$50K |
| D4910 |
|
624 |
618 |
$48K |
| D9430 |
|
1,114 |
1,003 |
$35K |
| D4341 |
|
493 |
132 |
$35K |
| D0350 |
|
2,979 |
1,294 |
$29K |
| D7240 |
Removal of impacted tooth - completely bony |
75 |
25 |
$17K |
| D8670 |
Periodic orthodontic treatment visit |
38 |
38 |
$11K |
| D1351 |
Sealant - per tooth |
458 |
120 |
$11K |
| D0330 |
Panoramic radiographic image |
288 |
285 |
$8K |
| D1206 |
Topical application of fluoride varnish |
472 |
466 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
44 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
39 |
25 |
$5K |
| D7230 |
|
23 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
326 |
308 |
$4K |
| D2330 |
|
48 |
36 |
$4K |
| D2954 |
|
31 |
28 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
52 |
$2K |
| D4342 |
|
38 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
12 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$288.00 |
| D1999 |
|
14 |
13 |
$0.00 |