| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,587 |
2,337 |
$121K |
| D2394 |
|
891 |
419 |
$95K |
| D0274 |
Bitewings - four radiographic images |
1,680 |
1,516 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,318 |
2,123 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,238 |
1,085 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
371 |
209 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,288 |
2,023 |
$28K |
| D0330 |
Panoramic radiographic image |
462 |
407 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,790 |
1,618 |
$24K |
| D1120 |
Prophylaxis - child |
853 |
765 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,806 |
1,554 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
99 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
225 |
79 |
$11K |
| D1351 |
Sealant - per tooth |
343 |
57 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
112 |
$5K |
| D0272 |
Bitewings - two radiographic images |
56 |
51 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
40 |
34 |
$937.79 |
| D1999 |
|
1,403 |
1,295 |
$615.00 |
| D1330 |
|
93 |
79 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
12 |
$0.00 |
| D0350 |
|
562 |
480 |
$0.00 |