| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,443 |
2,443 |
$122K |
| D0274 |
Bitewings - four radiographic images |
3,278 |
3,278 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
3,384 |
3,384 |
$77K |
| D1206 |
Topical application of fluoride varnish |
4,059 |
4,059 |
$66K |
| D0220 |
Intraoral - periapical first radiographic image |
4,487 |
4,422 |
$57K |
| D1120 |
Prophylaxis - child |
1,520 |
1,520 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,180 |
4,107 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
360 |
240 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
321 |
321 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
79 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
65 |
46 |
$5K |
| D0272 |
Bitewings - two radiographic images |
248 |
248 |
$5K |
| D1351 |
Sealant - per tooth |
74 |
28 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
48 |
$1K |