| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,576 |
1,574 |
$71K |
| D1206 |
Topical application of fluoride varnish |
2,202 |
2,200 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
924 |
552 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,043 |
2,041 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
514 |
337 |
$28K |
| D1120 |
Prophylaxis - child |
544 |
544 |
$24K |
| D1351 |
Sealant - per tooth |
1,005 |
239 |
$20K |
| D0274 |
Bitewings - four radiographic images |
1,471 |
1,470 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
366 |
366 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,046 |
2,040 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,863 |
1,857 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
202 |
199 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
98 |
83 |
$8K |
| D1353 |
|
771 |
149 |
$8K |
| D0603 |
|
449 |
449 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
174 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
149 |
147 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
184 |
184 |
$2K |
| D2950 |
|
15 |
12 |
$660.00 |
| D0270 |
|
13 |
13 |
$65.00 |