| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,005 |
994 |
$20K |
| D1110 |
Prophylaxis - adult |
675 |
665 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
1,426 |
1,410 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,312 |
1,298 |
$16K |
| D9920 |
|
433 |
420 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
39 |
$6K |
| D0272 |
Bitewings - two radiographic images |
494 |
487 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
40 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
215 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
157 |
142 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
196 |
191 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D0274 |
Bitewings - four radiographic images |
108 |
108 |
$932.88 |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
170 |
$392.31 |
| D0230 |
Intraoral - periapical each additional radiographic image |
59 |
57 |
$0.00 |
| D1351 |
Sealant - per tooth |
48 |
12 |
$0.00 |