| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,533 |
2,531 |
$187K |
| D1110 |
Prophylaxis - adult |
583 |
580 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
344 |
185 |
$20K |
| D1351 |
Sealant - per tooth |
2,768 |
753 |
$7K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
3,010 |
3,003 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
66 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
117 |
$771.96 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$599.83 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
479 |
434 |
$129.39 |
| D0220 |
Intraoral - periapical first radiographic image |
245 |
244 |
$35.85 |
| D0272 |
Bitewings - two radiographic images |
1,664 |
1,663 |
$15.87 |
| D1206 |
Topical application of fluoride varnish |
91 |
91 |
$13.55 |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
67 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,885 |
2,880 |
$-400.65 |