| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,952 |
2,947 |
$144K |
| D0120 |
Periodic oral evaluation - established patient |
2,178 |
2,174 |
$97K |
| D1206 |
Topical application of fluoride varnish |
2,853 |
2,829 |
$86K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
896 |
870 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
308 |
222 |
$43K |
| D0272 |
Bitewings - two radiographic images |
1,118 |
1,118 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,204 |
1,189 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
440 |
440 |
$22K |
| D0603 |
|
2,185 |
2,183 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
92 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
546 |
497 |
$8K |
| D1351 |
Sealant - per tooth |
187 |
72 |
$8K |
| D1330 |
|
2,305 |
2,301 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
57 |
57 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$2K |
| D1354 |
|
56 |
15 |
$780.30 |
| D1999 |
|
72 |
67 |
$504.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$367.20 |