| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,779 |
1,769 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
2,047 |
2,035 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,222 |
2,214 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
185 |
112 |
$20K |
| D1110 |
Prophylaxis - adult |
328 |
323 |
$20K |
| D0272 |
Bitewings - two radiographic images |
445 |
441 |
$13K |
| D1351 |
Sealant - per tooth |
263 |
92 |
$11K |
| D0274 |
Bitewings - four radiographic images |
144 |
144 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
224 |
207 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
30 |
$4K |
| D9310 |
|
28 |
28 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
47 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
15 |
$930.00 |
| D0240 |
|
27 |
14 |
$598.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$529.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
13 |
$265.00 |
| D0340 |
|
12 |
12 |
$0.00 |