| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,733 |
1,727 |
$43K |
| D1206 |
Topical application of fluoride varnish |
2,026 |
2,020 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,734 |
1,725 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
113 |
$14K |
| D1110 |
Prophylaxis - adult |
326 |
323 |
$12K |
| D0272 |
Bitewings - two radiographic images |
659 |
656 |
$11K |
| D0603 |
|
1,040 |
1,034 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
215 |
210 |
$8K |
| D1330 |
|
1,549 |
1,541 |
$8K |
| D1351 |
Sealant - per tooth |
242 |
53 |
$6K |
| D0330 |
Panoramic radiographic image |
93 |
93 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
152 |
152 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
286 |
285 |
$2K |
| D0602 |
|
233 |
232 |
$2K |
| D0601 |
|
220 |
219 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
118 |
$996.03 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$934.32 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$375.00 |
| D1310 |
|
514 |
509 |
$12.00 |