| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,393 |
5,392 |
$481K |
| D1110 |
Prophylaxis - adult |
3,343 |
3,343 |
$366K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,890 |
1,061 |
$130K |
| D0330 |
Panoramic radiographic image |
592 |
592 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
481 |
334 |
$22K |
| D1351 |
Sealant - per tooth |
7,538 |
2,000 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
8,395 |
8,394 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
123 |
123 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
94 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,897 |
1,799 |
$375.56 |
| D0274 |
Bitewings - four radiographic images |
2,471 |
2,471 |
$164.19 |
| D0272 |
Bitewings - two radiographic images |
3,957 |
3,953 |
$97.01 |
| D0220 |
Intraoral - periapical first radiographic image |
7,246 |
7,203 |
$87.05 |
| D1206 |
Topical application of fluoride varnish |
8,660 |
8,659 |
$13.55 |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,297 |
6,205 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
292 |
292 |
$0.00 |
| D1354 |
|
137 |
39 |
$0.00 |