| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
609 |
513 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
313 |
138 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
449 |
368 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
621 |
534 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
597 |
509 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
355 |
240 |
$8K |
| D0274 |
Bitewings - four radiographic images |
362 |
298 |
$8K |
| D1351 |
Sealant - per tooth |
289 |
48 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
255 |
185 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
745 |
578 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
151 |
133 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
26 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
88 |
68 |
$1K |
| D0330 |
Panoramic radiographic image |
19 |
13 |
$903.28 |
| D1206 |
Topical application of fluoride varnish |
72 |
55 |
$778.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
27 |
$271.30 |