| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,121 |
1,067 |
$51K |
| D1110 |
Prophylaxis - adult |
367 |
330 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
192 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
1,304 |
1,221 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
29 |
$4K |
| D0999 |
Unspecified diagnostic procedure, by report |
179 |
143 |
$3K |
| D1351 |
Sealant - per tooth |
276 |
64 |
$2K |
| D0274 |
Bitewings - four radiographic images |
539 |
483 |
$2K |
| D1330 |
|
842 |
761 |
$943.07 |
| D1206 |
Topical application of fluoride varnish |
649 |
582 |
$857.94 |
| D1208 |
Topical application of fluoride, excluding varnish |
863 |
836 |
$526.77 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,331 |
1,201 |
$458.22 |
| D0220 |
Intraoral - periapical first radiographic image |
1,407 |
1,286 |
$404.54 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
12 |
$378.16 |
| D0272 |
Bitewings - two radiographic images |
390 |
366 |
$172.17 |
| D1999 |
|
130 |
125 |
$77.70 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
12 |
$62.44 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
28 |
$0.00 |