| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
921 |
901 |
$25K |
| D1120 |
Prophylaxis - child |
602 |
583 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
142 |
142 |
$20K |
| D1110 |
Prophylaxis - adult |
365 |
362 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
965 |
944 |
$14K |
| D0274 |
Bitewings - four radiographic images |
374 |
370 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
123 |
74 |
$12K |
| D0272 |
Bitewings - two radiographic images |
536 |
521 |
$12K |
| D0350 |
|
329 |
302 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
366 |
354 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
117 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
32 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
200 |
$3K |
| D1351 |
Sealant - per tooth |
94 |
35 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
32 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
41 |
39 |
$1K |
| D0603 |
|
1,220 |
1,198 |
$0.00 |