| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,614 |
2,592 |
$141K |
| D0120 |
Periodic oral evaluation - established patient |
4,634 |
4,604 |
$132K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,037 |
6,858 |
$129K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,272 |
704 |
$126K |
| D1120 |
Prophylaxis - child |
3,435 |
3,409 |
$125K |
| D0274 |
Bitewings - four radiographic images |
3,320 |
3,301 |
$106K |
| D0145 |
Oral evaluation for a patient under three years of age |
756 |
752 |
$105K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,848 |
6,794 |
$99K |
| D1351 |
Sealant - per tooth |
3,074 |
524 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
7,417 |
7,343 |
$76K |
| D0272 |
Bitewings - two radiographic images |
2,595 |
2,571 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,445 |
1,430 |
$50K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,295 |
1,206 |
$34K |
| D0330 |
Panoramic radiographic image |
657 |
651 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
102 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
63 |
12 |
$9K |
| D9248 |
|
76 |
74 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
126 |
126 |
$8K |
| D1330 |
|
135 |
135 |
$2K |
| D0603 |
|
6,877 |
6,803 |
$0.00 |
| D0601 |
|
808 |
806 |
$0.00 |