| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,159 |
4,124 |
$29K |
| D1206 |
Topical application of fluoride varnish |
5,468 |
5,401 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
4,005 |
3,963 |
$20K |
| D1351 |
Sealant - per tooth |
1,920 |
522 |
$16K |
| D1110 |
Prophylaxis - adult |
1,110 |
1,101 |
$5K |
| D0272 |
Bitewings - two radiographic images |
1,506 |
1,502 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,797 |
1,790 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
839 |
835 |
$2K |
| D1353 |
|
39 |
15 |
$777.66 |
| D0220 |
Intraoral - periapical first radiographic image |
3,093 |
3,072 |
$593.34 |
| D0350 |
|
605 |
588 |
$0.00 |
| D0330 |
Panoramic radiographic image |
526 |
525 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
463 |
434 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
65 |
$0.00 |
| D1354 |
|
50 |
26 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
33 |
33 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,502 |
2,793 |
$0.00 |
| D0603 |
|
1,184 |
1,123 |
$0.00 |
| D0601 |
|
405 |
400 |
$0.00 |
| D0602 |
|
311 |
304 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
533 |
312 |
$0.00 |