| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,020 |
3,006 |
$9K |
| D1206 |
Topical application of fluoride varnish |
3,363 |
3,348 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
2,629 |
2,614 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
460 |
457 |
$2K |
| D0272 |
Bitewings - two radiographic images |
795 |
784 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
947 |
940 |
$430.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
600 |
600 |
$249.21 |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$195.86 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
24 |
$173.16 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
105 |
97 |
$157.17 |
| D0330 |
Panoramic radiographic image |
125 |
124 |
$135.26 |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$78.87 |
| D0350 |
|
42 |
42 |
$0.00 |
| D1321 |
|
12 |
12 |
$0.00 |