| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
652 |
640 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
859 |
840 |
$23K |
| D1206 |
Topical application of fluoride varnish |
723 |
707 |
$18K |
| D1110 |
Prophylaxis - adult |
218 |
217 |
$11K |
| D0274 |
Bitewings - four radiographic images |
262 |
261 |
$9K |
| D0272 |
Bitewings - two radiographic images |
254 |
254 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
90 |
90 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
31 |
$3K |
| D1330 |
|
379 |
379 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
147 |
147 |
$2K |
| D1351 |
Sealant - per tooth |
33 |
16 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
18 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
72 |
$963.55 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$809.00 |
| D0240 |
|
61 |
33 |
$780.00 |
| D1353 |
|
38 |
16 |
$778.26 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$693.75 |
| D0603 |
|
107 |
107 |
$0.00 |