| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,625 |
4,542 |
$125K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
970 |
559 |
$111K |
| D1206 |
Topical application of fluoride varnish |
4,318 |
4,235 |
$101K |
| D1110 |
Prophylaxis - adult |
1,737 |
1,709 |
$95K |
| D1120 |
Prophylaxis - child |
1,801 |
1,760 |
$72K |
| D0274 |
Bitewings - four radiographic images |
1,090 |
1,065 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
110 |
$16K |
| D7240 |
Removal of impacted tooth - completely bony |
38 |
12 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$3K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$2K |
| D0272 |
Bitewings - two radiographic images |
108 |
103 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
59 |
54 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
51 |
$432.00 |