| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,634 |
1,628 |
$195.55 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,446 |
1,963 |
$139.90 |
| D0120 |
Periodic oral evaluation - established patient |
1,353 |
1,349 |
$104.68 |
| D1206 |
Topical application of fluoride varnish |
1,522 |
1,515 |
$97.35 |
| D0220 |
Intraoral - periapical first radiographic image |
2,203 |
2,165 |
$78.47 |
| D0272 |
Bitewings - two radiographic images |
837 |
834 |
$63.09 |
| D0330 |
Panoramic radiographic image |
155 |
154 |
$0.00 |
| D1110 |
Prophylaxis - adult |
333 |
330 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
174 |
165 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
531 |
526 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
611 |
604 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
75 |
$0.00 |
| D0602 |
|
299 |
295 |
$0.00 |
| D0603 |
|
95 |
93 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$0.00 |
| D0601 |
|
69 |
68 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
555 |
554 |
$0.00 |
| D1351 |
Sealant - per tooth |
89 |
29 |
$0.00 |