| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
397 |
397 |
$19K |
| D1206 |
Topical application of fluoride varnish |
874 |
874 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
683 |
683 |
$14K |
| D1120 |
Prophylaxis - child |
261 |
261 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
43 |
$7K |
| D0274 |
Bitewings - four radiographic images |
149 |
149 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
260 |
258 |
$3K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
42 |
13 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
183 |
174 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
14 |
$2K |
| D9310 |
|
12 |
12 |
$915.09 |
| D9222 |
|
14 |
13 |
$896.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
17 |
$607.32 |
| D3120 |
|
20 |
14 |
$368.20 |