| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,254 |
5,226 |
$190K |
| D1206 |
Topical application of fluoride varnish |
6,475 |
6,426 |
$131K |
| D0120 |
Periodic oral evaluation - established patient |
4,897 |
4,873 |
$122K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
776 |
486 |
$100K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,690 |
3,660 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,433 |
1,424 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
4,411 |
4,358 |
$56K |
| D1110 |
Prophylaxis - adult |
925 |
925 |
$47K |
| D0272 |
Bitewings - two radiographic images |
2,009 |
2,000 |
$43K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,306 |
1,192 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
406 |
283 |
$42K |
| D1351 |
Sealant - per tooth |
455 |
185 |
$16K |
| D0330 |
Panoramic radiographic image |
236 |
224 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
206 |
205 |
$8K |
| D0274 |
Bitewings - four radiographic images |
141 |
141 |
$4K |
| D4346 |
|
49 |
49 |
$2K |
| D0350 |
|
13 |
12 |
$663.24 |
| D9310 |
|
14 |
14 |
$583.94 |