| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
946 |
946 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
397 |
271 |
$42K |
| D1206 |
Topical application of fluoride varnish |
2,044 |
2,029 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,124 |
1,124 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,514 |
1,514 |
$32K |
| D0330 |
Panoramic radiographic image |
645 |
645 |
$32K |
| D1120 |
Prophylaxis - child |
916 |
916 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
191 |
131 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
823 |
791 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,384 |
1,338 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
633 |
633 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
636 |
581 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
82 |
39 |
$10K |
| D1351 |
Sealant - per tooth |
374 |
90 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
859 |
756 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
56 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
27 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$259.08 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$237.90 |