| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,353 |
1,343 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,367 |
1,350 |
$27K |
| D1120 |
Prophylaxis - child |
948 |
940 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
440 |
407 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
297 |
190 |
$17K |
| D1110 |
Prophylaxis - adult |
318 |
315 |
$11K |
| D1351 |
Sealant - per tooth |
369 |
73 |
$9K |
| D0272 |
Bitewings - two radiographic images |
563 |
556 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
39 |
$3K |
| D0274 |
Bitewings - four radiographic images |
86 |
86 |
$2K |
| D2140 |
|
51 |
42 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
74 |
$2K |
| D0603 |
|
190 |
190 |
$2K |
| D1330 |
|
325 |
325 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
81 |
80 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$936.52 |
| D0240 |
|
20 |
16 |
$373.20 |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
31 |
$278.72 |
| D0601 |
|
27 |
27 |
$271.50 |
| D0602 |
|
25 |
25 |
$252.53 |
| D1310 |
|
20 |
20 |
$216.00 |