| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,122 |
2,122 |
$57K |
| D1120 |
Prophylaxis - child |
1,435 |
1,433 |
$48K |
| D1110 |
Prophylaxis - adult |
848 |
848 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,162 |
1,159 |
$36K |
| D1206 |
Topical application of fluoride varnish |
2,327 |
2,325 |
$31K |
| D1351 |
Sealant - per tooth |
1,422 |
306 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
389 |
238 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
261 |
156 |
$19K |
| D0272 |
Bitewings - two radiographic images |
705 |
705 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
961 |
944 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
812 |
686 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
245 |
225 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
166 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
85 |
82 |
$663.80 |
| D0603 |
|
1,575 |
1,572 |
$0.00 |
| D0602 |
|
411 |
411 |
$0.00 |
| D0601 |
|
336 |
335 |
$0.00 |