| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,907 |
2,768 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,488 |
2,485 |
$54K |
| D1120 |
Prophylaxis - child |
1,992 |
1,991 |
$51K |
| D1351 |
Sealant - per tooth |
1,895 |
427 |
$43K |
| D1110 |
Prophylaxis - adult |
966 |
964 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,481 |
1,480 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,393 |
1,390 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,717 |
2,756 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
3,023 |
2,979 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
494 |
494 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
69 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
143 |
84 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
158 |
158 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
255 |
236 |
$7K |
| D0240 |
|
810 |
406 |
$6K |
| D2140 |
|
99 |
71 |
$5K |
| D1999 |
|
513 |
473 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
70 |
$2K |
| D0330 |
Panoramic radiographic image |
267 |
266 |
$591.93 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$264.00 |