| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
4,948 |
4,727 |
$124K |
| D0120 |
Periodic oral evaluation - established patient |
2,911 |
2,908 |
$73K |
| D1120 |
Prophylaxis - child |
2,338 |
2,337 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
778 |
393 |
$63K |
| D1110 |
Prophylaxis - adult |
1,617 |
1,611 |
$60K |
| D0274 |
Bitewings - four radiographic images |
2,583 |
2,580 |
$55K |
| D1351 |
Sealant - per tooth |
1,096 |
195 |
$34K |
| D1999 |
|
3,183 |
2,950 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
615 |
579 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
675 |
675 |
$15K |
| D0240 |
|
1,342 |
677 |
$10K |
| D0330 |
Panoramic radiographic image |
261 |
261 |
$10K |
| D0272 |
Bitewings - two radiographic images |
215 |
215 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
304 |
297 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
26 |
$876.43 |
| D9986 |
|
34 |
31 |
$0.00 |