| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,857 |
2,847 |
$80K |
| D1120 |
Prophylaxis - child |
1,747 |
1,736 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,447 |
3,432 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
480 |
286 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
2,701 |
2,687 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,213 |
2,197 |
$25K |
| D1351 |
Sealant - per tooth |
812 |
195 |
$23K |
| D1110 |
Prophylaxis - adult |
394 |
393 |
$21K |
| D0272 |
Bitewings - two radiographic images |
837 |
836 |
$19K |
| D0330 |
Panoramic radiographic image |
181 |
180 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
386 |
349 |
$10K |
| D0274 |
Bitewings - four radiographic images |
218 |
218 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
40 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$4K |
| D0240 |
|
193 |
183 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$918.32 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$883.00 |
| D0603 |
|
4,924 |
4,900 |
$0.00 |