| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,600 |
4,299 |
$184K |
| D1351 |
Sealant - per tooth |
1,958 |
1,037 |
$116K |
| D1206 |
Topical application of fluoride varnish |
4,522 |
4,223 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
3,230 |
3,036 |
$89K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,155 |
730 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,900 |
1,771 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,700 |
1,572 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
3,240 |
3,009 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
427 |
328 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
887 |
827 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,918 |
2,502 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
242 |
176 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,024 |
974 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
130 |
99 |
$9K |
| D0330 |
Panoramic radiographic image |
357 |
343 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
417 |
383 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
50 |
$4K |
| D0270 |
|
210 |
190 |
$1K |
| D9310 |
|
57 |
55 |
$906.30 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
26 |
$754.00 |
| D1110 |
Prophylaxis - adult |
17 |
15 |
$697.00 |
| D1999 |
|
1,573 |
1,291 |
$0.00 |