| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
728 |
728 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,175 |
1,163 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
614 |
614 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
427 |
426 |
$10K |
| D0603 |
|
1,006 |
1,001 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
104 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
287 |
285 |
$6K |
| D0272 |
Bitewings - two radiographic images |
247 |
247 |
$5K |
| D4341 |
|
225 |
108 |
$5K |
| D1110 |
Prophylaxis - adult |
199 |
199 |
$5K |
| D1351 |
Sealant - per tooth |
144 |
39 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
534 |
190 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
346 |
342 |
$4K |
| D0240 |
|
182 |
106 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
139 |
94 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
126 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
81 |
81 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
68 |
67 |
$2K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$2K |
| D1354 |
|
926 |
254 |
$1K |
| D0330 |
Panoramic radiographic image |
130 |
129 |
$1K |
| D0602 |
|
61 |
61 |
$316.25 |
| D0191 |
|
14 |
14 |
$72.00 |
| D1320 |
|
13 |
13 |
$50.00 |
| D1330 |
|
666 |
642 |
$50.00 |
| D1310 |
|
584 |
568 |
$10.00 |
| D3120 |
|
71 |
55 |
$0.00 |