| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,380 |
1,004 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
2,026 |
1,458 |
$31K |
| D1351 |
Sealant - per tooth |
1,565 |
204 |
$22K |
| D1120 |
Prophylaxis - child |
1,005 |
740 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,192 |
868 |
$17K |
| D0274 |
Bitewings - four radiographic images |
639 |
424 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
290 |
149 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
195 |
137 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
431 |
309 |
$10K |
| D0330 |
Panoramic radiographic image |
428 |
286 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
233 |
139 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
229 |
168 |
$7K |
| D1206 |
Topical application of fluoride varnish |
482 |
358 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
259 |
216 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
20 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
176 |
123 |
$2K |
| D0272 |
Bitewings - two radiographic images |
56 |
40 |
$396.96 |
| D0277 |
|
64 |
38 |
$0.00 |