| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,884 |
3,407 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,130 |
1,721 |
$67K |
| D1206 |
Topical application of fluoride varnish |
3,104 |
2,724 |
$67K |
| D1351 |
Sealant - per tooth |
2,159 |
395 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,815 |
1,708 |
$50K |
| D0330 |
Panoramic radiographic image |
951 |
746 |
$33K |
| D0274 |
Bitewings - four radiographic images |
507 |
465 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
332 |
288 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
132 |
72 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
565 |
317 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
377 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
623 |
555 |
$7K |
| D0272 |
Bitewings - two radiographic images |
355 |
301 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
53 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
65 |
$731.69 |
| D1330 |
|
45 |
45 |
$0.00 |