| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,216 |
3,187 |
$66K |
| D1120 |
Prophylaxis - child |
1,984 |
1,971 |
$59K |
| D1110 |
Prophylaxis - adult |
1,195 |
1,174 |
$53K |
| D1206 |
Topical application of fluoride varnish |
3,145 |
3,112 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
413 |
248 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
678 |
653 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
582 |
547 |
$15K |
| D0274 |
Bitewings - four radiographic images |
487 |
475 |
$15K |
| D0330 |
Panoramic radiographic image |
234 |
232 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
545 |
509 |
$8K |
| D0272 |
Bitewings - two radiographic images |
294 |
294 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
124 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
277 |
137 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
105 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D0603 |
|
122 |
122 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
14 |
$1K |
| D1351 |
Sealant - per tooth |
42 |
13 |
$1K |
| D0602 |
|
48 |
48 |
$420.90 |