| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
7,360 |
7,360 |
$400K |
| D0120 |
Periodic oral evaluation - established patient |
9,747 |
9,747 |
$267K |
| D1120 |
Prophylaxis - child |
5,314 |
5,312 |
$222K |
| D0274 |
Bitewings - four radiographic images |
5,695 |
5,695 |
$158K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,598 |
1,191 |
$154K |
| D1351 |
Sealant - per tooth |
1,662 |
760 |
$102K |
| D2160 |
|
846 |
610 |
$101K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,571 |
6,571 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,360 |
2,360 |
$68K |
| D7140 |
Extraction, erupted tooth or exposed root |
954 |
711 |
$56K |
| D0330 |
Panoramic radiographic image |
1,248 |
1,248 |
$38K |
| D2140 |
|
477 |
413 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
348 |
294 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
1,073 |
1,070 |
$29K |
| D2332 |
|
91 |
50 |
$15K |
| D2161 |
|
91 |
81 |
$14K |
| D2335 |
|
72 |
42 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
193 |
152 |
$11K |
| D2750 |
|
13 |
13 |
$8K |
| D2330 |
|
85 |
61 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
67 |
55 |
$7K |
| D0272 |
Bitewings - two radiographic images |
349 |
349 |
$6K |
| D1206 |
Topical application of fluoride varnish |
183 |
182 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
58 |
$763.56 |