| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,158 |
1,850 |
$73K |
| D1206 |
Topical application of fluoride varnish |
2,494 |
2,165 |
$67K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,452 |
2,706 |
$62K |
| D0330 |
Panoramic radiographic image |
1,924 |
1,691 |
$53K |
| D0274 |
Bitewings - four radiographic images |
2,094 |
1,847 |
$40K |
| D1351 |
Sealant - per tooth |
2,532 |
379 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
1,398 |
1,216 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
3,219 |
2,834 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,433 |
1,232 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
651 |
570 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
409 |
101 |
$10K |
| D2140 |
|
440 |
105 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
161 |
48 |
$7K |
| D0272 |
Bitewings - two radiographic images |
272 |
264 |
$5K |
| D0703 |
|
397 |
388 |
$4K |
| D0602 |
|
1,287 |
1,068 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
154 |
37 |
$4K |
| D1110 |
Prophylaxis - adult |
109 |
103 |
$4K |
| D0999 |
Unspecified diagnostic procedure, by report |
63 |
63 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
31 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
104 |
104 |
$2K |
| D0170 |
|
222 |
158 |
$1K |
| D1353 |
|
55 |
12 |
$980.72 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
13 |
$904.05 |
| D1999 |
|
39 |
39 |
$585.00 |
| D4355 |
|
55 |
44 |
$350.00 |
| D9110 |
|
93 |
61 |
$306.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
27 |
$245.76 |
| D0603 |
|
105 |
94 |
$179.00 |
| D0601 |
|
56 |
55 |
$43.00 |
| D0350 |
|
45 |
41 |
$0.00 |
| D1330 |
|
163 |
142 |
$0.00 |