| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,901 |
1,901 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
1,815 |
1,815 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
571 |
418 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,323 |
1,323 |
$40K |
| D1120 |
Prophylaxis - child |
772 |
772 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
774 |
774 |
$22K |
| D0330 |
Panoramic radiographic image |
506 |
505 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
319 |
228 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
955 |
955 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
669 |
667 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
137 |
137 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
83 |
47 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
447 |
447 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
37 |
$4K |
| D1351 |
Sealant - per tooth |
117 |
31 |
$4K |
| D2335 |
|
14 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
14 |
$2K |
| D2332 |
|
17 |
13 |
$2K |
| D9945 |
|
12 |
12 |
$2K |
| D4910 |
|
29 |
29 |
$2K |
| D0160 |
|
18 |
18 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$665.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$399.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$313.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$260.30 |
| D0270 |
|
13 |
13 |
$172.90 |