| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
988 |
985 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,139 |
1,136 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,021 |
1,019 |
$23K |
| D1351 |
Sealant - per tooth |
367 |
100 |
$12K |
| D1110 |
Prophylaxis - adult |
201 |
201 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
79 |
$9K |
| D0272 |
Bitewings - two radiographic images |
337 |
335 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
52 |
$7K |
| D0274 |
Bitewings - four radiographic images |
190 |
190 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
125 |
$4K |
| D1330 |
|
196 |
196 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
123 |
$2K |
| D0240 |
|
48 |
46 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
36 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$521.50 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$386.75 |