| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
3,646 |
3,175 |
$146K |
| D1120 |
Prophylaxis - child |
2,782 |
2,447 |
$119K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,393 |
668 |
$110K |
| D1351 |
Sealant - per tooth |
2,865 |
776 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,747 |
2,404 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,743 |
1,511 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,658 |
1,471 |
$41K |
| D1354 |
|
3,230 |
771 |
$36K |
| D1110 |
Prophylaxis - adult |
842 |
765 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,650 |
1,394 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,719 |
2,340 |
$26K |
| D2160 |
|
219 |
150 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,564 |
3,162 |
$21K |
| D0330 |
Panoramic radiographic image |
864 |
782 |
$20K |
| D1353 |
|
1,472 |
460 |
$17K |
| D2140 |
|
293 |
194 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
456 |
410 |
$13K |
| D9991 |
|
1,176 |
1,119 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,314 |
1,125 |
$10K |
| D9215 |
|
1,827 |
1,235 |
$10K |
| D0272 |
Bitewings - two radiographic images |
408 |
330 |
$6K |
| D4346 |
|
61 |
38 |
$6K |
| D3120 |
|
189 |
102 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
41 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
25 |
$1K |
| D7111 |
|
33 |
15 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$688.80 |
| D0240 |
|
156 |
115 |
$70.70 |
| D1999 |
|
670 |
557 |
$0.00 |