| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
825 |
801 |
$50K |
| D1120 |
Prophylaxis - child |
1,117 |
1,081 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
460 |
224 |
$47K |
| D1351 |
Sealant - per tooth |
827 |
240 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,078 |
1,045 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
252 |
148 |
$21K |
| D0274 |
Bitewings - four radiographic images |
239 |
234 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
258 |
248 |
$8K |
| D0330 |
Panoramic radiographic image |
72 |
70 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
101 |
85 |
$6K |
| D0272 |
Bitewings - two radiographic images |
192 |
183 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$397.88 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$242.06 |
| D1330 |
|
27 |
25 |
$0.00 |