| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
631 |
579 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,116 |
580 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
52 |
$10K |
| D1110 |
Prophylaxis - adult |
205 |
193 |
$10K |
| D1351 |
Sealant - per tooth |
350 |
99 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
656 |
611 |
$9K |
| D1120 |
Prophylaxis - child |
234 |
229 |
$8K |
| D0274 |
Bitewings - four radiographic images |
259 |
246 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
707 |
644 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
26 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
151 |
139 |
$4K |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$1K |
| D0350 |
|
35 |
29 |
$496.26 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
14 |
$459.16 |
| D0603 |
|
833 |
808 |
$0.00 |