| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,505 |
6,505 |
$359K |
| D0120 |
Periodic oral evaluation - established patient |
8,160 |
8,160 |
$226K |
| D0274 |
Bitewings - four radiographic images |
5,045 |
5,045 |
$135K |
| D1120 |
Prophylaxis - child |
3,059 |
3,059 |
$130K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,181 |
1,132 |
$129K |
| D0330 |
Panoramic radiographic image |
2,811 |
2,811 |
$104K |
| D1351 |
Sealant - per tooth |
687 |
577 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,752 |
4,752 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
494 |
482 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
603 |
568 |
$50K |
| D0272 |
Bitewings - two radiographic images |
2,829 |
2,829 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
522 |
491 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,289 |
1,289 |
$38K |
| D2140 |
|
395 |
385 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
1,616 |
1,613 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,709 |
1,705 |
$23K |
| D2160 |
|
181 |
176 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
892 |
892 |
$11K |
| D1354 |
|
518 |
100 |
$8K |
| D9996 |
|
362 |
340 |
$5K |
| D1206 |
Topical application of fluoride varnish |
123 |
123 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
15 |
$2K |
| D2330 |
|
12 |
12 |
$872.32 |
| D9110 |
|
30 |
30 |
$838.68 |
| D0140 |
Limited oral evaluation - problem focused |
66 |
66 |
$826.00 |