| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,710 |
1,709 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
878 |
574 |
$61K |
| D1206 |
Topical application of fluoride varnish |
1,736 |
1,735 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,895 |
1,895 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
476 |
475 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,405 |
1,405 |
$17K |
| D1120 |
Prophylaxis - child |
368 |
368 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
286 |
186 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
233 |
231 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,880 |
1,879 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,647 |
1,647 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
274 |
$7K |
| D0603 |
|
554 |
553 |
$6K |
| D1351 |
Sealant - per tooth |
264 |
62 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
192 |
178 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
37 |
$4K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
12 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$160.00 |