| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,994 |
1,978 |
$51K |
| D1110 |
Prophylaxis - adult |
1,217 |
1,207 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
367 |
217 |
$40K |
| D1120 |
Prophylaxis - child |
1,026 |
1,020 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,648 |
1,638 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
576 |
570 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,096 |
1,060 |
$17K |
| D0274 |
Bitewings - four radiographic images |
487 |
482 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,218 |
699 |
$15K |
| D0330 |
Panoramic radiographic image |
239 |
237 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
26 |
$3K |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$888.21 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$613.34 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$514.02 |