| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
647 |
643 |
$15K |
| D1206 |
Topical application of fluoride varnish |
715 |
710 |
$11K |
| D1120 |
Prophylaxis - child |
442 |
438 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
68 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
113 |
$4K |
| D1110 |
Prophylaxis - adult |
98 |
98 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
172 |
152 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
38 |
$3K |
| D0272 |
Bitewings - two radiographic images |
243 |
240 |
$2K |
| D1351 |
Sealant - per tooth |
131 |
50 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
70 |
70 |
$2K |
| D1999 |
|
104 |
87 |
$1K |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$496.80 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$237.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
14 |
$35.55 |