| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,074 |
2,069 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
1,071 |
1,065 |
$69K |
| D1110 |
Prophylaxis - adult |
647 |
646 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
765 |
765 |
$48K |
| D1206 |
Topical application of fluoride varnish |
3,136 |
3,118 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
576 |
266 |
$31K |
| D0350 |
|
3,190 |
1,318 |
$28K |
| D9430 |
|
792 |
702 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,649 |
1,855 |
$14K |
| D4910 |
|
182 |
182 |
$14K |
| D0274 |
Bitewings - four radiographic images |
671 |
670 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
259 |
259 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
74 |
$9K |
| D9993 |
|
115 |
115 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
173 |
151 |
$5K |
| D1310 |
|
116 |
115 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
50 |
$5K |
| D0272 |
Bitewings - two radiographic images |
384 |
384 |
$4K |
| D1351 |
Sealant - per tooth |
169 |
40 |
$4K |
| D4341 |
|
44 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
221 |
216 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |
| D0601 |
|
13 |
13 |
$195.00 |
| D0603 |
|
12 |
12 |
$180.00 |