| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,706 |
1,689 |
$27K |
| D1206 |
Topical application of fluoride varnish |
2,085 |
2,059 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
907 |
894 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
426 |
230 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
326 |
194 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
1,129 |
1,120 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,007 |
998 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,346 |
1,307 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,582 |
1,225 |
$7K |
| D0330 |
Panoramic radiographic image |
440 |
433 |
$7K |
| D1110 |
Prophylaxis - adult |
229 |
226 |
$5K |
| D0274 |
Bitewings - four radiographic images |
358 |
356 |
$4K |
| D1351 |
Sealant - per tooth |
407 |
155 |
$4K |
| D0350 |
|
363 |
315 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
357 |
327 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
55 |
$546.55 |
| D1330 |
|
325 |
314 |
$0.00 |