| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,947 |
1,643 |
$100K |
| D1110 |
Prophylaxis - adult |
729 |
589 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
385 |
183 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
270 |
236 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
2,304 |
1,915 |
$16K |
| D0340 |
|
177 |
176 |
$10K |
| D0330 |
Panoramic radiographic image |
254 |
254 |
$4K |
| D1351 |
Sealant - per tooth |
141 |
48 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
31 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
265 |
171 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,763 |
1,453 |
$959.27 |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$892.15 |
| D0140 |
Limited oral evaluation - problem focused |
41 |
39 |
$520.77 |
| D0274 |
Bitewings - four radiographic images |
708 |
567 |
$280.61 |
| D1330 |
|
2,723 |
2,277 |
$70.91 |
| D0220 |
Intraoral - periapical first radiographic image |
1,893 |
1,549 |
$65.00 |
| D0240 |
|
661 |
553 |
$59.89 |
| D1206 |
Topical application of fluoride varnish |
2,674 |
2,238 |
$58.26 |
| D0272 |
Bitewings - two radiographic images |
1,639 |
1,389 |
$16.38 |
| D0350 |
|
160 |
159 |
$5.00 |