| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
229 |
205 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
38 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
36 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
352 |
322 |
$8K |
| D1120 |
Prophylaxis - child |
218 |
202 |
$7K |
| D1206 |
Topical application of fluoride varnish |
328 |
305 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
98 |
$4K |
| D1351 |
Sealant - per tooth |
113 |
39 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
16 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
110 |
101 |
$3K |
| D0274 |
Bitewings - four radiographic images |
92 |
87 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
29 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
134 |
$2K |
| D0272 |
Bitewings - two radiographic images |
70 |
68 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
34 |
29 |
$1K |
| D0330 |
Panoramic radiographic image |
21 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
69 |
$997.66 |