| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,365 |
3,292 |
$136K |
| D1206 |
Topical application of fluoride varnish |
2,822 |
2,761 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,525 |
2,470 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
965 |
766 |
$69K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
735 |
552 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,375 |
1,345 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
521 |
390 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,023 |
1,005 |
$17K |
| D1351 |
Sealant - per tooth |
214 |
129 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
204 |
193 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
104 |
98 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,501 |
1,454 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
300 |
291 |
$7K |
| D0272 |
Bitewings - two radiographic images |
725 |
710 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,198 |
1,032 |
$6K |
| D0330 |
Panoramic radiographic image |
276 |
270 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
318 |
309 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
227 |
210 |
$5K |
| D1110 |
Prophylaxis - adult |
112 |
107 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
52 |
36 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
13 |
12 |
$2K |
| D2140 |
|
30 |
14 |
$894.65 |
| D9310 |
|
14 |
13 |
$222.30 |