| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,115 |
2,549 |
$110K |
| D1206 |
Topical application of fluoride varnish |
5,649 |
4,705 |
$93K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,654 |
645 |
$84K |
| D1120 |
Prophylaxis - child |
2,472 |
2,103 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
3,306 |
2,738 |
$67K |
| D0330 |
Panoramic radiographic image |
2,294 |
1,861 |
$64K |
| D0274 |
Bitewings - four radiographic images |
3,457 |
2,845 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,512 |
2,092 |
$60K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,297 |
1,660 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
432 |
210 |
$28K |
| D2740 |
Crown - porcelain/ceramic |
57 |
29 |
$19K |
| D9945 |
|
91 |
47 |
$12K |
| D5110 |
|
19 |
14 |
$9K |
| D1351 |
Sealant - per tooth |
309 |
104 |
$9K |
| D0272 |
Bitewings - two radiographic images |
648 |
558 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
438 |
339 |
$4K |
| D2330 |
|
20 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
15 |
$341.60 |
| D1999 |
|
1,156 |
920 |
$0.00 |
| D1354 |
|
40 |
14 |
$0.00 |