| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
365 |
319 |
$11K |
| D1351 |
Sealant - per tooth |
423 |
54 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
664 |
599 |
$8K |
| D0272 |
Bitewings - two radiographic images |
326 |
310 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
647 |
597 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
237 |
230 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
193 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
604 |
555 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
16 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
17 |
$3K |
| D1110 |
Prophylaxis - adult |
44 |
43 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
38 |
34 |
$553.76 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
16 |
$515.09 |
| D0330 |
Panoramic radiographic image |
23 |
20 |
$83.14 |
| D0350 |
|
14 |
13 |
$18.38 |
| D0603 |
|
973 |
882 |
$0.00 |