| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,929 |
4,927 |
$427K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,518 |
1,670 |
$181K |
| D1120 |
Prophylaxis - child |
2,769 |
2,763 |
$158K |
| D0210 |
Intraoral - complete series of radiographic images |
484 |
484 |
$75K |
| D0330 |
Panoramic radiographic image |
1,050 |
1,050 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
753 |
753 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
76 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
369 |
234 |
$10K |
| D1351 |
Sealant - per tooth |
3,428 |
567 |
$6K |
| D0274 |
Bitewings - four radiographic images |
4,596 |
4,594 |
$754.60 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$403.40 |
| D0120 |
Periodic oral evaluation - established patient |
6,940 |
6,930 |
$297.48 |
| D0220 |
Intraoral - periapical first radiographic image |
3,922 |
3,892 |
$54.55 |
| D0272 |
Bitewings - two radiographic images |
933 |
930 |
$15.87 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,991 |
1,991 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
23 |
17 |
$0.00 |
| D1999 |
|
33 |
33 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,360 |
3,244 |
$-95.24 |
| D1206 |
Topical application of fluoride varnish |
5,354 |
5,345 |
$-123.92 |