| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,172 |
4,709 |
$307K |
| D0120 |
Periodic oral evaluation - established patient |
5,165 |
4,704 |
$225K |
| D1206 |
Topical application of fluoride varnish |
5,207 |
4,758 |
$209K |
| D1351 |
Sealant - per tooth |
1,233 |
707 |
$165K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,208 |
850 |
$143K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,526 |
1,252 |
$142K |
| D1110 |
Prophylaxis - adult |
1,122 |
1,026 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,770 |
1,618 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
843 |
700 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
864 |
809 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,229 |
1,145 |
$33K |
| D0330 |
Panoramic radiographic image |
725 |
645 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,540 |
1,393 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
652 |
561 |
$5K |
| D2331 |
|
42 |
37 |
$4K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
286 |
275 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
20 |
$1K |
| D2330 |
|
12 |
12 |
$484.40 |
| D9310 |
|
12 |
12 |
$360.00 |
| 90686 |
|
15 |
15 |
$156.20 |
| G0008 |
Administration of influenza virus vaccine |
19 |
19 |
$96.00 |
| 99173 |
|
13 |
13 |
$91.00 |