| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
287 |
286 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
71 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
240 |
240 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
563 |
529 |
$3K |
| D0191 |
|
128 |
125 |
$3K |
| D2952 |
|
14 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
27 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
78 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
142 |
142 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
63 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
330 |
328 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$990.00 |
| D0601 |
|
307 |
307 |
$570.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$560.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$437.50 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$315.00 |
| D0270 |
|
30 |
28 |
$150.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$140.00 |