| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,498 |
2,484 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
2,724 |
2,713 |
$67K |
| D1206 |
Topical application of fluoride varnish |
2,685 |
2,669 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
485 |
276 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,393 |
1,386 |
$19K |
| D1110 |
Prophylaxis - adult |
317 |
317 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
115 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
471 |
460 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
41 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
165 |
165 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
139 |
132 |
$2K |
| D0240 |
|
78 |
78 |
$2K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$369.46 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$188.28 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
25 |
$123.91 |
| D1330 |
|
240 |
224 |
$0.00 |