| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,542 |
3,724 |
$96K |
| D1206 |
Topical application of fluoride varnish |
3,935 |
3,246 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
2,702 |
2,280 |
$58K |
| D0330 |
Panoramic radiographic image |
2,046 |
1,632 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
649 |
387 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,883 |
1,544 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
950 |
743 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,127 |
871 |
$26K |
| D1351 |
Sealant - per tooth |
1,230 |
156 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,370 |
969 |
$9K |
| D0350 |
|
477 |
341 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
44 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
49 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
319 |
234 |
$3K |
| D0272 |
Bitewings - two radiographic images |
199 |
169 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
105 |
29 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
528 |
120 |
$2K |
| D1110 |
Prophylaxis - adult |
53 |
36 |
$669.68 |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
13 |
$580.37 |
| D1330 |
|
770 |
579 |
$0.00 |