| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,365 |
1,080 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,620 |
1,291 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
412 |
252 |
$28K |
| D0330 |
Panoramic radiographic image |
493 |
395 |
$20K |
| D0274 |
Bitewings - four radiographic images |
794 |
633 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
194 |
151 |
$18K |
| D1120 |
Prophylaxis - child |
600 |
489 |
$13K |
| D1206 |
Topical application of fluoride varnish |
968 |
770 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,291 |
565 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
383 |
300 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,060 |
834 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
210 |
176 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
166 |
129 |
$6K |
| D0272 |
Bitewings - two radiographic images |
230 |
195 |
$3K |
| D1351 |
Sealant - per tooth |
167 |
31 |
$3K |
| D2330 |
|
49 |
37 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
188 |
177 |
$2K |
| D2140 |
|
34 |
15 |
$2K |
| D0240 |
|
80 |
66 |
$1K |
| D4355 |
|
13 |
13 |
$770.84 |