| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
880 |
880 |
$18K |
| D1110 |
Prophylaxis - adult |
321 |
321 |
$14K |
| D1206 |
Topical application of fluoride varnish |
752 |
752 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
45 |
$9K |
| D1120 |
Prophylaxis - child |
265 |
265 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
506 |
503 |
$7K |
| D0330 |
Panoramic radiographic image |
113 |
113 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
660 |
245 |
$5K |
| D0274 |
Bitewings - four radiographic images |
164 |
164 |
$5K |
| D1351 |
Sealant - per tooth |
185 |
54 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
128 |
128 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$842.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$494.10 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$384.16 |
| D0603 |
|
27 |
27 |
$237.90 |