| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,198 |
1,189 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,117 |
1,101 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,130 |
1,126 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
135 |
$15K |
| D1120 |
Prophylaxis - child |
204 |
204 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
156 |
146 |
$6K |
| D0274 |
Bitewings - four radiographic images |
494 |
494 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
888 |
880 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
51 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
169 |
169 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
148 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
704 |
702 |
$3K |
| D1351 |
Sealant - per tooth |
130 |
30 |
$3K |
| D0603 |
|
149 |
149 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
47 |
45 |
$1K |
| D0272 |
Bitewings - two radiographic images |
73 |
73 |
$730.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$495.00 |