| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,383 |
1,374 |
$107K |
| D1110 |
Prophylaxis - adult |
721 |
715 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
273 |
238 |
$22K |
| D1351 |
Sealant - per tooth |
1,041 |
392 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
208 |
191 |
$12K |
| D0340 |
|
185 |
182 |
$11K |
| D0330 |
Panoramic radiographic image |
306 |
304 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
42 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
164 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
189 |
180 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
1,964 |
1,949 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,557 |
1,520 |
$395.83 |
| D0220 |
Intraoral - periapical first radiographic image |
1,646 |
1,629 |
$100.00 |
| D3120 |
|
89 |
80 |
$60.00 |
| D0350 |
|
171 |
168 |
$60.00 |
| D0272 |
Bitewings - two radiographic images |
1,192 |
1,185 |
$46.76 |
| D0240 |
|
464 |
460 |
$38.38 |
| D1206 |
Topical application of fluoride varnish |
2,013 |
2,000 |
$29.35 |
| D0274 |
Bitewings - four radiographic images |
686 |
679 |
$16.35 |
| D1330 |
|
2,102 |
2,087 |
$3.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$0.00 |