| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
9,228 |
9,150 |
$315K |
| D1110 |
Prophylaxis - adult |
3,148 |
3,119 |
$208K |
| D0120 |
Periodic oral evaluation - established patient |
11,727 |
11,621 |
$164K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,335 |
10,274 |
$147K |
| D0330 |
Panoramic radiographic image |
579 |
575 |
$56K |
| D0274 |
Bitewings - four radiographic images |
3,037 |
3,006 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
436 |
301 |
$26K |
| D1206 |
Topical application of fluoride varnish |
12,697 |
12,587 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
300 |
$17K |
| D1351 |
Sealant - per tooth |
3,799 |
918 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
11,197 |
11,060 |
$9K |
| D1330 |
|
12,939 |
12,823 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
130 |
92 |
$6K |
| D0272 |
Bitewings - two radiographic images |
4,134 |
4,099 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,079 |
1,032 |
$4K |
| D0601 |
|
8,492 |
8,412 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
35 |
33 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$795.78 |
| D0603 |
|
1,278 |
1,269 |
$530.00 |
| D1354 |
|
30 |
14 |
$170.61 |
| D0602 |
|
212 |
212 |
$25.00 |
| D1999 |
|
73 |
73 |
$0.00 |