| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,468 |
2,465 |
$110K |
| D1206 |
Topical application of fluoride varnish |
2,319 |
2,318 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,628 |
2,625 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
771 |
431 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
719 |
331 |
$40K |
| D1120 |
Prophylaxis - child |
562 |
562 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,838 |
1,836 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
473 |
473 |
$21K |
| D2740 |
Crown - porcelain/ceramic |
34 |
27 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,608 |
2,594 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
285 |
283 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,148 |
2,139 |
$12K |
| D1351 |
Sealant - per tooth |
566 |
123 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
415 |
415 |
$10K |
| D0330 |
Panoramic radiographic image |
185 |
185 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
54 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
240 |
238 |
$6K |
| D0603 |
|
384 |
384 |
$4K |
| D0272 |
Bitewings - two radiographic images |
193 |
193 |
$2K |
| D1353 |
|
130 |
34 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
44 |
42 |
$1K |
| D2950 |
|
19 |
14 |
$1K |
| D0601 |
|
34 |
34 |
$340.00 |