| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
455 |
453 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
763 |
763 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
295 |
290 |
$13K |
| D1120 |
Prophylaxis - child |
247 |
247 |
$11K |
| D1206 |
Topical application of fluoride varnish |
341 |
340 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
65 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
323 |
322 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
158 |
$7K |
| D0274 |
Bitewings - four radiographic images |
441 |
441 |
$6K |
| D0330 |
Panoramic radiographic image |
135 |
135 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
804 |
787 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
636 |
634 |
$3K |
| D1351 |
Sealant - per tooth |
109 |
15 |
$2K |
| D9110 |
|
27 |
26 |
$810.00 |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$756.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$665.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$639.00 |