| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,824 |
1,824 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
881 |
511 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
2,325 |
2,325 |
$53K |
| D1206 |
Topical application of fluoride varnish |
2,663 |
2,663 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,408 |
1,408 |
$39K |
| D1120 |
Prophylaxis - child |
901 |
901 |
$31K |
| D0330 |
Panoramic radiographic image |
397 |
397 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
521 |
488 |
$17K |
| D1351 |
Sealant - per tooth |
452 |
131 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
163 |
$7K |
| D0272 |
Bitewings - two radiographic images |
214 |
214 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$1K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
12 |
12 |
$1K |
| D9222 |
|
12 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$462.00 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$372.07 |