| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,490 |
2,385 |
$28K |
| D1206 |
Topical application of fluoride varnish |
2,696 |
2,580 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
1,320 |
1,272 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,862 |
1,768 |
$8K |
| D0272 |
Bitewings - two radiographic images |
1,175 |
1,123 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
624 |
595 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,393 |
1,322 |
$5K |
| D1351 |
Sealant - per tooth |
384 |
125 |
$4K |
| D0330 |
Panoramic radiographic image |
364 |
348 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
68 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
201 |
185 |
$2K |
| D0350 |
|
204 |
96 |
$583.03 |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$566.77 |
| D0140 |
Limited oral evaluation - problem focused |
34 |
34 |
$441.94 |
| D0145 |
Oral evaluation for a patient under three years of age |
37 |
37 |
$386.84 |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$355.06 |
| D1354 |
|
36 |
12 |
$335.16 |
| D9310 |
|
14 |
14 |
$119.73 |
| D0603 |
|
45 |
42 |
$0.00 |
| D1330 |
|
159 |
151 |
$0.00 |