| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,131 |
2,110 |
$51K |
| D1206 |
Topical application of fluoride varnish |
2,279 |
2,260 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,399 |
1,381 |
$29K |
| D0603 |
|
1,421 |
1,406 |
$14K |
| D0272 |
Bitewings - two radiographic images |
720 |
711 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
85 |
$12K |
| D1330 |
|
1,811 |
1,792 |
$9K |
| D1351 |
Sealant - per tooth |
360 |
67 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
394 |
391 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
293 |
292 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
436 |
427 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
333 |
318 |
$3K |
| D1110 |
Prophylaxis - adult |
75 |
75 |
$3K |
| D9248 |
|
14 |
14 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
35 |
$1K |
| D0601 |
|
128 |
127 |
$1K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$1K |
| D0602 |
|
94 |
91 |
$880.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$851.91 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$459.80 |
| D1310 |
|
1,320 |
1,307 |
$29.00 |