| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,699 |
2,681 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
758 |
456 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
3,454 |
3,431 |
$77K |
| D1206 |
Topical application of fluoride varnish |
3,620 |
3,591 |
$71K |
| D1110 |
Prophylaxis - adult |
1,279 |
1,271 |
$49K |
| D0274 |
Bitewings - four radiographic images |
943 |
937 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,593 |
1,576 |
$21K |
| D1351 |
Sealant - per tooth |
549 |
149 |
$14K |
| D0272 |
Bitewings - two radiographic images |
556 |
556 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,294 |
1,263 |
$10K |
| D0330 |
Panoramic radiographic image |
162 |
162 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
241 |
240 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
28 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$1K |
| D0240 |
|
26 |
13 |
$425.08 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$0.00 |