| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,125 |
1,804 |
$78K |
| D1351 |
Sealant - per tooth |
3,195 |
482 |
$60K |
| D1206 |
Topical application of fluoride varnish |
2,102 |
1,790 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
821 |
719 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,064 |
877 |
$20K |
| D0350 |
|
3,952 |
1,658 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
1,099 |
905 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
2,025 |
1,703 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,980 |
1,600 |
$9K |
| D0272 |
Bitewings - two radiographic images |
504 |
441 |
$7K |
| D0330 |
Panoramic radiographic image |
166 |
164 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
122 |
$5K |
| D0603 |
|
979 |
945 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
314 |
231 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
102 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
196 |
170 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
58 |
$3K |
| D0602 |
|
437 |
421 |
$2K |
| D7111 |
|
40 |
31 |
$775.00 |
| D1353 |
|
47 |
12 |
$705.20 |
| D3120 |
|
37 |
19 |
$144.00 |
| D0601 |
|
43 |
41 |
$35.00 |
| D9986 |
|
17 |
16 |
$0.00 |