| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,485 |
1,377 |
$72K |
| D1110 |
Prophylaxis - adult |
1,804 |
1,651 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,758 |
2,541 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
790 |
501 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,743 |
1,598 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,048 |
968 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
822 |
779 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
307 |
220 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,656 |
1,484 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
350 |
329 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,301 |
643 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
135 |
94 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
51 |
$4K |
| D0272 |
Bitewings - two radiographic images |
240 |
208 |
$4K |
| D1351 |
Sealant - per tooth |
246 |
60 |
$4K |
| D2335 |
|
23 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
33 |
32 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
12 |
$624.00 |
| D9986 |
|
901 |
812 |
$615.00 |