| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
188 |
185 |
$6K |
| D1206 |
Topical application of fluoride varnish |
266 |
260 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
166 |
161 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
32 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
21 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
123 |
$3K |
| D1110 |
Prophylaxis - adult |
63 |
59 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
64 |
63 |
$2K |
| D9248 |
|
18 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
138 |
$1K |
| D1351 |
Sealant - per tooth |
37 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
24 |
$827.32 |
| D0230 |
Intraoral - periapical each additional radiographic image |
113 |
104 |
$762.56 |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$718.15 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$565.60 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$542.29 |
| D0272 |
Bitewings - two radiographic images |
35 |
34 |
$406.20 |