| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,104 |
1,099 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
566 |
560 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
563 |
561 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,270 |
1,263 |
$28K |
| D1310 |
|
763 |
757 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,247 |
986 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
146 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
316 |
314 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
294 |
257 |
$10K |
| D0350 |
|
767 |
315 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
688 |
661 |
$6K |
| D0603 |
|
496 |
490 |
$6K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$4K |
| D0274 |
Bitewings - four radiographic images |
214 |
214 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
27 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$2K |
| D1206 |
Topical application of fluoride varnish |
122 |
122 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
16 |
16 |
$2K |
| D1320 |
|
104 |
104 |
$1K |
| D9430 |
|
27 |
27 |
$744.00 |
| D0272 |
Bitewings - two radiographic images |
50 |
49 |
$462.00 |
| D0602 |
|
31 |
31 |
$401.25 |
| D1999 |
|
121 |
111 |
$80.50 |
| D1330 |
|
270 |
266 |
$0.00 |
| D9993 |
|
416 |
411 |
$0.00 |