| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
353 |
344 |
$10K |
| D0330 |
Panoramic radiographic image |
72 |
69 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
228 |
$4K |
| D1110 |
Prophylaxis - adult |
46 |
46 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
15 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
196 |
193 |
$268.68 |
| D1351 |
Sealant - per tooth |
36 |
12 |
$155.28 |
| D1330 |
|
533 |
518 |
$64.25 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
25 |
$41.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
529 |
514 |
$16.42 |
| D0272 |
Bitewings - two radiographic images |
222 |
217 |
$0.00 |
| D0601 |
|
323 |
319 |
$0.00 |
| D0602 |
|
15 |
15 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
31 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$0.00 |
| D9986 |
|
25 |
25 |
$0.00 |