| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,606 |
1,589 |
$69K |
| D1206 |
Topical application of fluoride varnish |
2,289 |
2,260 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,848 |
1,828 |
$55K |
| D1110 |
Prophylaxis - adult |
137 |
136 |
$9K |
| D0272 |
Bitewings - two radiographic images |
549 |
542 |
$8K |
| D1330 |
|
826 |
817 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
17 |
$3K |
| D0330 |
Panoramic radiographic image |
78 |
77 |
$3K |
| D4355 |
|
28 |
27 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
89 |
81 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
77 |
$816.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$618.00 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$598.91 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$255.84 |