| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,575 |
6,474 |
$195K |
| D1120 |
Prophylaxis - child |
4,169 |
4,106 |
$183K |
| D1351 |
Sealant - per tooth |
5,089 |
1,061 |
$173K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,357 |
7,241 |
$168K |
| D1110 |
Prophylaxis - adult |
1,956 |
1,925 |
$119K |
| D0330 |
Panoramic radiographic image |
904 |
888 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,360 |
1,338 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
473 |
469 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
263 |
135 |
$25K |
| D1330 |
|
3,552 |
3,509 |
$22K |
| D1206 |
Topical application of fluoride varnish |
523 |
523 |
$14K |
| D0272 |
Bitewings - two radiographic images |
772 |
761 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
171 |
169 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
322 |
302 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
623 |
570 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
14 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
26 |
$215.00 |