| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,638 |
1,631 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
894 |
894 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,423 |
1,414 |
$23K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
29 |
28 |
$23K |
| D0274 |
Bitewings - four radiographic images |
887 |
885 |
$23K |
| D1120 |
Prophylaxis - child |
597 |
593 |
$20K |
| D0330 |
Panoramic radiographic image |
275 |
275 |
$17K |
| D2740 |
Crown - porcelain/ceramic |
18 |
16 |
$12K |
| D1206 |
Topical application of fluoride varnish |
269 |
263 |
$5K |
| D9310 |
|
54 |
54 |
$5K |
| D0272 |
Bitewings - two radiographic images |
72 |
72 |
$2K |
| D2950 |
|
12 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
33 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
38 |
33 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
97 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
45 |
$539.46 |
| D1208 |
Topical application of fluoride, excluding varnish |
106 |
102 |
$486.54 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$0.00 |