| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
383 |
381 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
687 |
682 |
$20K |
| D1120 |
Prophylaxis - child |
459 |
455 |
$17K |
| D0274 |
Bitewings - four radiographic images |
479 |
475 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,709 |
843 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
847 |
842 |
$12K |
| D0330 |
Panoramic radiographic image |
243 |
240 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
903 |
890 |
$8K |
| D0272 |
Bitewings - two radiographic images |
350 |
347 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
39 |
39 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
137 |
$5K |
| D1351 |
Sealant - per tooth |
143 |
29 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
108 |
97 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$2K |
| D1330 |
|
63 |
63 |
$661.50 |
| D0603 |
|
874 |
862 |
$0.00 |
| D0601 |
|
12 |
12 |
$0.00 |