| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,572 |
2,562 |
$114K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,050 |
697 |
$111K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,004 |
988 |
$25K |
| D9920 |
|
152 |
141 |
$13K |
| D1120 |
Prophylaxis - child |
101 |
101 |
$4K |
| D0603 |
|
332 |
329 |
$3K |
| D1206 |
Topical application of fluoride varnish |
88 |
88 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$2K |
| D0602 |
|
115 |
115 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$535.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$350.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$180.00 |
| D0601 |
|
13 |
13 |
$130.00 |