| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,531 |
3,528 |
$85K |
| D1120 |
Prophylaxis - child |
1,946 |
1,944 |
$62K |
| D1206 |
Topical application of fluoride varnish |
2,885 |
2,878 |
$59K |
| D1110 |
Prophylaxis - adult |
778 |
774 |
$32K |
| D0272 |
Bitewings - two radiographic images |
337 |
335 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
179 |
179 |
$4K |
| D0274 |
Bitewings - four radiographic images |
167 |
163 |
$4K |
| D0330 |
Panoramic radiographic image |
140 |
135 |
$3K |
| D1351 |
Sealant - per tooth |
78 |
26 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
29 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
143 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
21 |
$328.88 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
30 |
$211.39 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
33 |
13 |
$179.02 |
| D9248 |
|
22 |
20 |
$173.96 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$24.89 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
17 |
$13.06 |