| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,686 |
3,650 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
5,308 |
5,260 |
$158K |
| D1206 |
Topical application of fluoride varnish |
4,679 |
4,631 |
$117K |
| D0274 |
Bitewings - four radiographic images |
2,860 |
2,835 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,176 |
726 |
$82K |
| D0140 |
Limited oral evaluation - problem focused |
2,610 |
2,439 |
$76K |
| D0330 |
Panoramic radiographic image |
1,306 |
1,292 |
$69K |
| D1120 |
Prophylaxis - child |
1,676 |
1,658 |
$52K |
| D0272 |
Bitewings - two radiographic images |
859 |
847 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,884 |
1,835 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
435 |
301 |
$21K |
| D1351 |
Sealant - per tooth |
864 |
233 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
861 |
851 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
175 |
117 |
$15K |
| D2331 |
|
37 |
26 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
14 |
$2K |
| D2940 |
|
56 |
46 |
$925.74 |
| D9110 |
|
15 |
12 |
$580.19 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
36 |
$441.96 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
12 |
$261.04 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
36 |
28 |
$91.34 |
| D1999 |
|
644 |
561 |
$0.00 |
| D9995 |
|
260 |
257 |
$0.00 |