| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
965 |
965 |
$30K |
| D0274 |
Bitewings - four radiographic images |
826 |
826 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,071 |
1,071 |
$19K |
| D1110 |
Prophylaxis - adult |
404 |
404 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
323 |
323 |
$11K |
| D0240 |
|
554 |
362 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
582 |
580 |
$6K |
| D0330 |
Panoramic radiographic image |
143 |
143 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
517 |
509 |
$5K |
| D1206 |
Topical application of fluoride varnish |
221 |
221 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
27 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
141 |
141 |
$3K |
| D1351 |
Sealant - per tooth |
88 |
17 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
58 |
54 |
$2K |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$297.29 |