| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
8,956 |
1,782 |
$399K |
| D1120 |
Prophylaxis - child |
2,077 |
1,946 |
$102K |
| D1206 |
Topical application of fluoride varnish |
3,511 |
3,192 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
2,852 |
2,488 |
$96K |
| D1110 |
Prophylaxis - adult |
1,545 |
1,388 |
$90K |
| D1351 |
Sealant - per tooth |
1,910 |
395 |
$74K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
414 |
272 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
204 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,128 |
1,017 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
979 |
936 |
$44K |
| D9920 |
|
317 |
282 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,029 |
967 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
110 |
76 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
694 |
680 |
$29K |
| D0330 |
Panoramic radiographic image |
235 |
214 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
69 |
41 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
544 |
281 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
396 |
313 |
$7K |
| D0272 |
Bitewings - two radiographic images |
112 |
109 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
13 |
$3K |
| D0350 |
|
40 |
28 |
$924.15 |
| D0603 |
|
2,249 |
2,085 |
$0.00 |
| D0602 |
|
120 |
116 |
$0.00 |
| D0601 |
|
24 |
24 |
$0.00 |