| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,005 |
1,946 |
$20K |
| D1206 |
Topical application of fluoride varnish |
2,195 |
2,130 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
1,692 |
1,650 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
971 |
649 |
$5K |
| D0272 |
Bitewings - two radiographic images |
835 |
806 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
936 |
889 |
$3K |
| D0274 |
Bitewings - four radiographic images |
355 |
348 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
153 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
38 |
$2K |
| D1110 |
Prophylaxis - adult |
76 |
75 |
$1K |
| D1351 |
Sealant - per tooth |
202 |
64 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
197 |
180 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$984.75 |
| D0240 |
|
100 |
80 |
$723.94 |
| D1354 |
|
86 |
15 |
$292.78 |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
20 |
$212.77 |
| D0330 |
Panoramic radiographic image |
30 |
29 |
$150.16 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$146.44 |
| D0431 |
|
680 |
607 |
$0.00 |