| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,640 |
2,635 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
3,636 |
3,630 |
$86K |
| D1120 |
Prophylaxis - child |
1,869 |
1,869 |
$80K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,866 |
1,866 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
680 |
462 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
774 |
749 |
$33K |
| D0330 |
Panoramic radiographic image |
882 |
881 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
576 |
379 |
$30K |
| D0274 |
Bitewings - four radiographic images |
2,486 |
2,481 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
5,335 |
5,241 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,659 |
4,608 |
$17K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
28 |
24 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
661 |
661 |
$15K |
| D0272 |
Bitewings - two radiographic images |
844 |
844 |
$8K |
| D1351 |
Sealant - per tooth |
358 |
62 |
$6K |
| D0350 |
|
217 |
217 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
39 |
$3K |
| D2950 |
|
28 |
25 |
$1K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$781.25 |
| D2332 |
|
17 |
12 |
$630.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$325.00 |
| D9920 |
|
13 |
13 |
$325.00 |