| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,261 |
1,261 |
$116K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
609 |
351 |
$50K |
| D1120 |
Prophylaxis - child |
614 |
614 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
242 |
242 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
329 |
184 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
329 |
326 |
$6K |
| D1351 |
Sealant - per tooth |
591 |
127 |
$4K |
| D0274 |
Bitewings - four radiographic images |
751 |
750 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
1,901 |
1,899 |
$855.51 |
| D0220 |
Intraoral - periapical first radiographic image |
2,033 |
1,986 |
$190.12 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
44 |
$90.58 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,580 |
1,674 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
293 |
293 |
$0.00 |
| D1999 |
|
134 |
128 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,130 |
2,127 |
$-1102.92 |