| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,445 |
4,442 |
$199K |
| D1206 |
Topical application of fluoride varnish |
4,658 |
4,655 |
$145K |
| D0120 |
Periodic oral evaluation - established patient |
4,419 |
4,416 |
$110K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,312 |
1,203 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,826 |
1,821 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
132 |
$14K |
| D0330 |
Panoramic radiographic image |
271 |
270 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
927 |
920 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
36 |
$3K |
| D1110 |
Prophylaxis - adult |
94 |
92 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$853.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$620.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
113 |
112 |
$345.00 |