| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,681 |
2,681 |
$54K |
| D1120 |
Prophylaxis - child |
1,858 |
1,858 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
523 |
331 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,358 |
2,358 |
$34K |
| D1110 |
Prophylaxis - adult |
655 |
655 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
936 |
886 |
$24K |
| D0272 |
Bitewings - two radiographic images |
828 |
828 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
271 |
267 |
$8K |
| D0330 |
Panoramic radiographic image |
132 |
132 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
75 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
193 |
$5K |
| D0274 |
Bitewings - four radiographic images |
156 |
156 |
$5K |
| D1351 |
Sealant - per tooth |
49 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$386.02 |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$350.52 |