| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,196 |
1,153 |
$26K |
| D1120 |
Prophylaxis - child |
643 |
624 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
218 |
96 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
638 |
620 |
$15K |
| D1110 |
Prophylaxis - adult |
245 |
237 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
263 |
250 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
108 |
105 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
456 |
216 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
307 |
$3K |
| D0274 |
Bitewings - four radiographic images |
214 |
205 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
24 |
$2K |
| D1351 |
Sealant - per tooth |
74 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
160 |
150 |
$2K |
| D0330 |
Panoramic radiographic image |
188 |
184 |
$2K |
| D1999 |
|
350 |
277 |
$1K |
| D0367 |
|
162 |
154 |
$425.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
12 |
$420.32 |