| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,647 |
1,639 |
$78K |
| D1110 |
Prophylaxis - adult |
450 |
450 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
363 |
230 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
432 |
266 |
$20K |
| D0330 |
Panoramic radiographic image |
251 |
248 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
1,510 |
1,504 |
$10K |
| D1351 |
Sealant - per tooth |
1,370 |
319 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
517 |
514 |
$7K |
| D0272 |
Bitewings - two radiographic images |
1,188 |
1,177 |
$5K |
| D1206 |
Topical application of fluoride varnish |
1,700 |
1,697 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
642 |
589 |
$3K |
| D0274 |
Bitewings - four radiographic images |
330 |
330 |
$2K |
| D8670 |
Periodic orthodontic treatment visit |
26 |
24 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$887.87 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$873.24 |
| D1208 |
Topical application of fluoride, excluding varnish |
332 |
330 |
$323.00 |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
79 |
$117.00 |
| D0240 |
|
16 |
12 |
$48.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$0.00 |