| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,474 |
4,398 |
$117K |
| D1120 |
Prophylaxis - child |
3,233 |
3,180 |
$89K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,325 |
4,261 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
581 |
384 |
$61K |
| D1110 |
Prophylaxis - adult |
1,432 |
1,405 |
$55K |
| D1351 |
Sealant - per tooth |
1,614 |
455 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,263 |
1,555 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
1,801 |
1,739 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,331 |
1,315 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
224 |
173 |
$18K |
| D0274 |
Bitewings - four radiographic images |
294 |
291 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
151 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
113 |
111 |
$5K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$499.59 |