| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,521 |
1,323 |
$48K |
| D1110 |
Prophylaxis - adult |
506 |
471 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
88 |
$9K |
| D0330 |
Panoramic radiographic image |
114 |
109 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
168 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
110 |
99 |
$413.68 |
| D1351 |
Sealant - per tooth |
70 |
16 |
$194.10 |
| D1206 |
Topical application of fluoride varnish |
1,986 |
1,755 |
$92.56 |
| D0272 |
Bitewings - two radiographic images |
1,148 |
992 |
$89.62 |
| D0274 |
Bitewings - four radiographic images |
208 |
200 |
$71.68 |
| D0120 |
Periodic oral evaluation - established patient |
1,799 |
1,584 |
$55.25 |
| D1330 |
|
1,554 |
1,519 |
$6.00 |
| D9986 |
|
68 |
66 |
$0.00 |
| D9987 |
|
15 |
15 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$0.00 |