| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,990 |
1,772 |
$71K |
| D1206 |
Topical application of fluoride varnish |
1,967 |
1,750 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
662 |
377 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,014 |
912 |
$19K |
| D1351 |
Sealant - per tooth |
959 |
217 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,412 |
1,249 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
401 |
250 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,849 |
1,627 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
759 |
643 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
414 |
385 |
$10K |
| D0350 |
|
2,126 |
1,481 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,771 |
1,555 |
$9K |
| D0272 |
Bitewings - two radiographic images |
502 |
456 |
$7K |
| D7111 |
|
257 |
162 |
$7K |
| D0603 |
|
1,161 |
1,034 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
71 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
109 |
104 |
$2K |
| D0602 |
|
374 |
334 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$889.70 |
| D0601 |
|
66 |
60 |
$250.00 |
| D9986 |
|
39 |
39 |
$0.00 |