| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,445 |
2,428 |
$115K |
| D1206 |
Topical application of fluoride varnish |
2,948 |
2,932 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,247 |
2,233 |
$75K |
| D0140 |
Limited oral evaluation - problem focused |
2,034 |
1,938 |
$63K |
| D0330 |
Panoramic radiographic image |
1,160 |
1,155 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,944 |
1,935 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
749 |
499 |
$58K |
| D7140 |
Extraction, erupted tooth or exposed root |
662 |
331 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,426 |
1,418 |
$37K |
| D1120 |
Prophylaxis - child |
866 |
865 |
$30K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
276 |
117 |
$26K |
| D7230 |
|
71 |
36 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
856 |
831 |
$10K |
| D0272 |
Bitewings - two radiographic images |
276 |
276 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
207 |
138 |
$9K |
| D1351 |
Sealant - per tooth |
129 |
38 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
62 |
60 |
$320.92 |
| D1999 |
|
495 |
420 |
$20.00 |
| D9995 |
|
86 |
86 |
$0.00 |