| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,649 |
4,447 |
$278K |
| D0120 |
Periodic oral evaluation - established patient |
5,232 |
5,136 |
$201K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,424 |
1,433 |
$184K |
| D0274 |
Bitewings - four radiographic images |
3,631 |
3,581 |
$173K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,663 |
1,038 |
$159K |
| D1206 |
Topical application of fluoride varnish |
5,071 |
4,846 |
$152K |
| D0140 |
Limited oral evaluation - problem focused |
3,053 |
2,872 |
$122K |
| D1120 |
Prophylaxis - child |
2,647 |
2,526 |
$108K |
| D0330 |
Panoramic radiographic image |
1,001 |
996 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,700 |
1,603 |
$67K |
| D7140 |
Extraction, erupted tooth or exposed root |
726 |
349 |
$56K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
602 |
407 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
3,137 |
3,021 |
$53K |
| D0350 |
|
349 |
336 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,791 |
899 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
181 |
152 |
$19K |
| D2331 |
|
182 |
121 |
$19K |
| D2160 |
|
136 |
105 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
362 |
246 |
$14K |
| D1351 |
Sealant - per tooth |
322 |
111 |
$13K |
| D2335 |
|
73 |
50 |
$10K |
| D2140 |
|
118 |
93 |
$9K |
| D2330 |
|
89 |
61 |
$8K |
| D2161 |
|
40 |
39 |
$5K |
| D0272 |
Bitewings - two radiographic images |
126 |
125 |
$4K |
| D1330 |
|
136 |
133 |
$3K |
| D4355 |
|
43 |
43 |
$2K |
| D1354 |
|
24 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
28 |
$1K |
| D4910 |
|
13 |
13 |
$947.70 |
| D2940 |
|
15 |
14 |
$673.64 |
| D9410 |
|
16 |
16 |
$552.96 |
| D9996 |
|
87 |
87 |
$0.00 |