| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
802 |
773 |
$47K |
| D1110 |
Prophylaxis - adult |
230 |
224 |
$16K |
| D0330 |
Panoramic radiographic image |
87 |
83 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
83 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
81 |
16 |
$851.20 |
| D0120 |
Periodic oral evaluation - established patient |
915 |
886 |
$434.80 |
| D0272 |
Bitewings - two radiographic images |
659 |
637 |
$325.01 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
120 |
114 |
$291.34 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$189.57 |
| D1206 |
Topical application of fluoride varnish |
974 |
944 |
$189.44 |
| D0274 |
Bitewings - four radiographic images |
109 |
105 |
$118.10 |
| D0220 |
Intraoral - periapical first radiographic image |
466 |
448 |
$70.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
405 |
392 |
$0.00 |
| D1330 |
|
195 |
194 |
$0.00 |