| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,472 |
1,456 |
$72K |
| D1120 |
Prophylaxis - child |
1,262 |
1,245 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,738 |
1,702 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
699 |
426 |
$42K |
| D0330 |
Panoramic radiographic image |
1,045 |
1,031 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,543 |
1,532 |
$30K |
| D0274 |
Bitewings - four radiographic images |
959 |
944 |
$26K |
| D1351 |
Sealant - per tooth |
937 |
232 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,686 |
1,663 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
428 |
275 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,007 |
1,004 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,660 |
1,424 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
799 |
779 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
351 |
346 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,849 |
852 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
42 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
46 |
46 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
66 |
59 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
12 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
43 |
43 |
$860.20 |
| D1999 |
|
13 |
13 |
$0.00 |