| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,203 |
2,147 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
840 |
383 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,854 |
2,460 |
$17K |
| D1206 |
Topical application of fluoride varnish |
2,380 |
2,330 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
3,500 |
3,294 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
996 |
956 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
1,656 |
1,620 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
876 |
827 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
257 |
144 |
$5K |
| D1110 |
Prophylaxis - adult |
328 |
320 |
$4K |
| D0272 |
Bitewings - two radiographic images |
563 |
553 |
$3K |
| D0274 |
Bitewings - four radiographic images |
386 |
376 |
$3K |
| D1351 |
Sealant - per tooth |
270 |
81 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
212 |
196 |
$2K |
| D0330 |
Panoramic radiographic image |
191 |
186 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
59 |
$71.96 |
| D0603 |
|
705 |
666 |
$0.00 |
| D0601 |
|
97 |
97 |
$0.00 |
| D0602 |
|
324 |
310 |
$0.00 |