| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,234 |
3,182 |
$141K |
| D0120 |
Periodic oral evaluation - established patient |
4,491 |
4,409 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,019 |
597 |
$128K |
| D1110 |
Prophylaxis - adult |
2,004 |
1,961 |
$120K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,183 |
4,111 |
$96K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
570 |
387 |
$55K |
| D0330 |
Panoramic radiographic image |
1,131 |
1,117 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,462 |
1,434 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
564 |
556 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,248 |
1,224 |
$19K |
| D7240 |
Removal of impacted tooth - completely bony |
49 |
13 |
$15K |
| D1351 |
Sealant - per tooth |
336 |
84 |
$11K |
| D1206 |
Topical application of fluoride varnish |
442 |
429 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
806 |
789 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
504 |
504 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
12 |
$3K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
14 |
14 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
155 |
136 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$2K |
| D9222 |
|
14 |
14 |
$1K |