| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,283 |
3,233 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,668 |
3,609 |
$69K |
| D1110 |
Prophylaxis - adult |
743 |
728 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
351 |
349 |
$21K |
| D0330 |
Panoramic radiographic image |
252 |
249 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
101 |
$12K |
| D1206 |
Topical application of fluoride varnish |
3,068 |
3,015 |
$7K |
| D0272 |
Bitewings - two radiographic images |
2,280 |
2,241 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
232 |
216 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$1K |
| D1330 |
|
3,156 |
3,113 |
$998.63 |
| D0140 |
Limited oral evaluation - problem focused |
65 |
63 |
$797.52 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,047 |
1,040 |
$158.35 |
| D0274 |
Bitewings - four radiographic images |
308 |
301 |
$145.82 |
| D0220 |
Intraoral - periapical first radiographic image |
177 |
169 |
$108.52 |
| D1999 |
|
384 |
376 |
$4.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
89 |
85 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$0.00 |
| D9986 |
|
12 |
12 |
$0.00 |