| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,665 |
2,422 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
825 |
350 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
2,689 |
2,448 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,488 |
1,920 |
$13K |
| D1206 |
Topical application of fluoride varnish |
2,844 |
2,575 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
886 |
331 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,351 |
1,251 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
2,338 |
2,022 |
$7K |
| D0274 |
Bitewings - four radiographic images |
854 |
778 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
949 |
785 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
339 |
$4K |
| D1110 |
Prophylaxis - adult |
416 |
390 |
$3K |
| D1351 |
Sealant - per tooth |
992 |
215 |
$3K |
| D0330 |
Panoramic radiographic image |
244 |
223 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
72 |
$1K |
| D0240 |
|
115 |
64 |
$575.71 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
38 |
$447.92 |
| D3120 |
|
225 |
94 |
$415.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$133.92 |
| D1310 |
|
1,166 |
923 |
$0.00 |
| D1330 |
|
1,646 |
1,366 |
$0.00 |
| D4346 |
|
26 |
15 |
$0.00 |