| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,616 |
6,545 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
8,689 |
8,597 |
$2K |
| D1206 |
Topical application of fluoride varnish |
5,920 |
5,867 |
$2K |
| D1110 |
Prophylaxis - adult |
2,677 |
2,634 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,024 |
1,013 |
$1K |
| D0272 |
Bitewings - two radiographic images |
3,129 |
3,097 |
$901.90 |
| D0330 |
Panoramic radiographic image |
1,342 |
1,333 |
$899.09 |
| D0274 |
Bitewings - four radiographic images |
2,283 |
2,254 |
$838.43 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
631 |
345 |
$713.78 |
| D1351 |
Sealant - per tooth |
1,082 |
286 |
$397.08 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
340 |
218 |
$355.52 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,126 |
1,050 |
$314.98 |
| D0220 |
Intraoral - periapical first radiographic image |
1,880 |
1,818 |
$219.94 |
| D1208 |
Topical application of fluoride, excluding varnish |
3,463 |
3,412 |
$84.68 |
| D0140 |
Limited oral evaluation - problem focused |
135 |
131 |
$72.24 |
| D0240 |
|
127 |
81 |
$10.00 |
| D0603 |
|
1,574 |
1,514 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
126 |
124 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
311 |
303 |
$0.00 |
| D0601 |
|
602 |
582 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
12 |
$0.00 |