| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,527 |
2,389 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,781 |
730 |
$91K |
| D1206 |
Topical application of fluoride varnish |
2,486 |
2,360 |
$83K |
| D1351 |
Sealant - per tooth |
3,387 |
561 |
$70K |
| D0274 |
Bitewings - four radiographic images |
2,531 |
2,389 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,605 |
1,533 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
859 |
814 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,994 |
1,888 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
631 |
386 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,822 |
1,742 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,414 |
2,737 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
500 |
249 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
503 |
469 |
$15K |
| D0240 |
|
680 |
662 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
526 |
461 |
$9K |
| D1353 |
|
535 |
93 |
$8K |
| D0999 |
Unspecified diagnostic procedure, by report |
165 |
165 |
$5K |
| D0330 |
Panoramic radiographic image |
108 |
105 |
$4K |
| D9999 |
Unspecified adjunctive procedure, by report |
215 |
215 |
$4K |
| D0601 |
|
630 |
612 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
50 |
27 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
25 |
$2K |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$804.62 |
| D1999 |
|
53 |
53 |
$795.00 |
| D0603 |
|
100 |
97 |
$495.50 |
| D0602 |
|
13 |
12 |
$55.00 |