| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,004 |
990 |
$42K |
| D1206 |
Topical application of fluoride varnish |
2,250 |
2,219 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,669 |
1,639 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
291 |
187 |
$27K |
| D1120 |
Prophylaxis - child |
888 |
887 |
$26K |
| D0330 |
Panoramic radiographic image |
272 |
272 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
105 |
77 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
117 |
$9K |
| D0274 |
Bitewings - four radiographic images |
344 |
337 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
511 |
492 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
239 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
199 |
199 |
$6K |
| D0272 |
Bitewings - two radiographic images |
247 |
246 |
$4K |
| D1351 |
Sealant - per tooth |
96 |
28 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
224 |
138 |
$2K |
| D0350 |
|
27 |
27 |
$765.25 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
13 |
$411.60 |