| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,464 |
1,460 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
182 |
$20K |
| D1120 |
Prophylaxis - child |
1,562 |
1,555 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,835 |
1,830 |
$10K |
| D1110 |
Prophylaxis - adult |
124 |
124 |
$10K |
| D9920 |
|
272 |
269 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
82 |
$5K |
| D1351 |
Sealant - per tooth |
477 |
148 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,908 |
1,671 |
$4K |
| D1354 |
|
926 |
188 |
$3K |
| D0272 |
Bitewings - two radiographic images |
1,037 |
1,034 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
1,822 |
1,790 |
$3K |
| D0330 |
Panoramic radiographic image |
46 |
45 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
38 |
$2K |
| D1330 |
|
1,886 |
1,881 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
105 |
$1K |
| D0274 |
Bitewings - four radiographic images |
119 |
119 |
$703.05 |
| D9999 |
Unspecified adjunctive procedure, by report |
24 |
24 |
$540.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$507.28 |
| D0999 |
Unspecified diagnostic procedure, by report |
15 |
15 |
$300.00 |