| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,172 |
4,165 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
5,742 |
5,732 |
$63K |
| D1110 |
Prophylaxis - adult |
2,148 |
2,146 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,715 |
2,712 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,232 |
3,228 |
$16K |
| D0330 |
Panoramic radiographic image |
810 |
809 |
$11K |
| D0272 |
Bitewings - two radiographic images |
1,223 |
1,222 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
295 |
221 |
$5K |
| D1351 |
Sealant - per tooth |
428 |
134 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
166 |
124 |
$3K |
| D0274 |
Bitewings - four radiographic images |
455 |
455 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
136 |
136 |
$2K |
| D9997 |
|
57 |
57 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
26 |
$977.50 |
| D0140 |
Limited oral evaluation - problem focused |
168 |
168 |
$951.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$765.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
343 |
337 |
$522.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$182.60 |
| D1999 |
|
776 |
761 |
$0.00 |