| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
306 |
306 |
$10K |
| D1206 |
Topical application of fluoride varnish |
432 |
432 |
$9K |
| D1110 |
Prophylaxis - adult |
174 |
165 |
$7K |
| D0330 |
Panoramic radiographic image |
201 |
193 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
215 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
257 |
248 |
$6K |
| D9248 |
|
29 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
134 |
133 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
24 |
$2K |
| D1351 |
Sealant - per tooth |
65 |
17 |
$2K |
| D0274 |
Bitewings - four radiographic images |
90 |
84 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
62 |
58 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
26 |
$464.09 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
40 |
$425.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
13 |
$101.35 |