| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,074 |
4,982 |
$234K |
| D1120 |
Prophylaxis - child |
4,898 |
4,783 |
$159K |
| D0120 |
Periodic oral evaluation - established patient |
7,817 |
7,637 |
$152K |
| D1206 |
Topical application of fluoride varnish |
6,839 |
6,766 |
$140K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,527 |
972 |
$135K |
| D0274 |
Bitewings - four radiographic images |
2,943 |
2,900 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,018 |
671 |
$75K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,733 |
3,580 |
$75K |
| D9630 |
|
2,996 |
2,851 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
929 |
864 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,240 |
1,220 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,697 |
1,668 |
$33K |
| D1351 |
Sealant - per tooth |
290 |
80 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
288 |
280 |
$7K |
| D0330 |
Panoramic radiographic image |
137 |
128 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
479 |
471 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
27 |
$978.46 |