| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,677 |
4,674 |
$327K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,998 |
2,165 |
$312K |
| D1120 |
Prophylaxis - child |
1,328 |
1,328 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,219 |
940 |
$48K |
| D7140 |
Extraction, erupted tooth or exposed root |
818 |
423 |
$44K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
160 |
116 |
$31K |
| D0330 |
Panoramic radiographic image |
579 |
579 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
132 |
132 |
$16K |
| D2330 |
|
289 |
170 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,572 |
1,570 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
4,573 |
4,571 |
$6K |
| D0274 |
Bitewings - four radiographic images |
3,388 |
3,384 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
191 |
191 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,756 |
1,598 |
$2K |
| D1351 |
Sealant - per tooth |
57 |
13 |
$291.62 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,560 |
2,180 |
$110.24 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,617 |
2,614 |
$108.69 |
| D0272 |
Bitewings - two radiographic images |
383 |
383 |
$58.37 |
| D0230 |
Intraoral - periapical each additional radiographic image |
327 |
201 |
$0.00 |