| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,035 |
2,920 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,616 |
974 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
4,045 |
3,888 |
$82K |
| D0274 |
Bitewings - four radiographic images |
1,489 |
1,436 |
$46K |
| D1206 |
Topical application of fluoride varnish |
2,525 |
2,392 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
870 |
599 |
$36K |
| D1120 |
Prophylaxis - child |
1,070 |
1,037 |
$23K |
| D0330 |
Panoramic radiographic image |
438 |
412 |
$20K |
| D1351 |
Sealant - per tooth |
742 |
188 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
832 |
776 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
528 |
443 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
259 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
274 |
209 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
55 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
508 |
265 |
$2K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$446.58 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$404.16 |
| D3120 |
|
154 |
99 |
$0.00 |
| D0180 |
|
14 |
12 |
$0.00 |
| D1999 |
|
26 |
24 |
$0.00 |