| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,000 |
3,000 |
$149K |
| D0120 |
Periodic oral evaluation - established patient |
5,424 |
5,424 |
$126K |
| D1120 |
Prophylaxis - child |
3,435 |
3,435 |
$119K |
| D1206 |
Topical application of fluoride varnish |
6,572 |
6,572 |
$107K |
| D0274 |
Bitewings - four radiographic images |
3,087 |
3,087 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
736 |
478 |
$73K |
| D0272 |
Bitewings - two radiographic images |
2,297 |
2,297 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
2,623 |
2,605 |
$34K |
| D0330 |
Panoramic radiographic image |
692 |
692 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
540 |
540 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
274 |
182 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,811 |
1,776 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
39 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
205 |
197 |
$6K |
| D1351 |
Sealant - per tooth |
163 |
59 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
87 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$1K |