| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,592 |
2,586 |
$151K |
| D0210 |
Intraoral - complete series of radiographic images |
1,000 |
999 |
$149K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
640 |
390 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,289 |
735 |
$64K |
| D0330 |
Panoramic radiographic image |
1,532 |
1,529 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
777 |
199 |
$24K |
| D1120 |
Prophylaxis - child |
145 |
145 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,431 |
1,428 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
68 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
75 |
$2K |
| D0274 |
Bitewings - four radiographic images |
2,797 |
2,790 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
23 |
14 |
$743.56 |
| D0120 |
Periodic oral evaluation - established patient |
1,569 |
1,562 |
$188.68 |
| D1354 |
|
91 |
37 |
$68.00 |
| D1351 |
Sealant - per tooth |
572 |
119 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
2,102 |
2,052 |
$-72.69 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,840 |
2,832 |
$-198.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,971 |
1,608 |
$-388.03 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,598 |
2,261 |
$-562.02 |