| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,002 |
2,708 |
$122K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,818 |
987 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
2,668 |
2,403 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,816 |
1,621 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,421 |
2,188 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
595 |
383 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
238 |
135 |
$17K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
843 |
608 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
229 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
141 |
108 |
$5K |
| D1351 |
Sealant - per tooth |
117 |
13 |
$3K |
| D0330 |
Panoramic radiographic image |
54 |
48 |
$2K |
| D5110 |
|
15 |
12 |
$872.70 |
| D0140 |
Limited oral evaluation - problem focused |
138 |
114 |
$567.32 |
| D3120 |
|
18 |
12 |
$0.00 |