| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,527 |
3,329 |
$1.15M |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,281 |
1,045 |
$292K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
644 |
244 |
$110K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
68 |
$30K |
| D1206 |
Topical application of fluoride varnish |
5,541 |
4,277 |
$7K |
| D1110 |
Prophylaxis - adult |
1,657 |
1,202 |
$676.67 |
| D0274 |
Bitewings - four radiographic images |
1,411 |
966 |
$516.80 |
| D1120 |
Prophylaxis - child |
3,343 |
2,490 |
$279.58 |
| D1351 |
Sealant - per tooth |
3,035 |
451 |
$263.76 |
| D0220 |
Intraoral - periapical first radiographic image |
1,232 |
890 |
$123.70 |
| D0272 |
Bitewings - two radiographic images |
1,175 |
816 |
$98.45 |
| D0230 |
Intraoral - periapical each additional radiographic image |
816 |
333 |
$26.22 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
350 |
206 |
$0.00 |
| D0330 |
Panoramic radiographic image |
305 |
203 |
$0.00 |
| D1354 |
|
27 |
12 |
$0.00 |
| D1330 |
|
625 |
520 |
$0.00 |