| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,682 |
1,585 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,211 |
1,160 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
293 |
219 |
$20K |
| D1206 |
Topical application of fluoride varnish |
694 |
662 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
667 |
629 |
$17K |
| D1351 |
Sealant - per tooth |
176 |
134 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
616 |
578 |
$13K |
| D1110 |
Prophylaxis - adult |
270 |
254 |
$8K |
| D0274 |
Bitewings - four radiographic images |
362 |
346 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
948 |
894 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
756 |
717 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
41 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
85 |
$756.46 |
| D0140 |
Limited oral evaluation - problem focused |
44 |
41 |
$680.40 |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$588.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12 |
12 |
$524.45 |
| D1330 |
|
59 |
58 |
$0.00 |