| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,068 |
980 |
$49K |
| D1120 |
Prophylaxis - child |
1,127 |
1,035 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,460 |
1,308 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
439 |
261 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,676 |
1,517 |
$20K |
| D0274 |
Bitewings - four radiographic images |
603 |
556 |
$14K |
| D0330 |
Panoramic radiographic image |
407 |
367 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
133 |
$12K |
| D0272 |
Bitewings - two radiographic images |
440 |
405 |
$8K |
| D1206 |
Topical application of fluoride varnish |
491 |
466 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
181 |
171 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
112 |
103 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
244 |
$2K |
| D1351 |
Sealant - per tooth |
143 |
17 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
47 |
$2K |
| D0350 |
|
470 |
447 |
$786.92 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
12 |
$649.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
24 |
$368.20 |
| D0603 |
|
1,205 |
1,095 |
$31.00 |
| D0602 |
|
390 |
335 |
$2.00 |
| D1999 |
|
503 |
463 |
$0.00 |