| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,065 |
3,420 |
$149K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,239 |
927 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
4,019 |
3,399 |
$96K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,850 |
4,082 |
$95K |
| D0330 |
Panoramic radiographic image |
1,540 |
1,333 |
$86K |
| D1110 |
Prophylaxis - adult |
1,233 |
1,060 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
378 |
306 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,253 |
1,032 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,430 |
1,181 |
$33K |
| D1351 |
Sealant - per tooth |
1,085 |
124 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
446 |
400 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
245 |
191 |
$8K |
| D0274 |
Bitewings - four radiographic images |
202 |
171 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
25 |
$396.50 |
| D1330 |
|
223 |
212 |
$0.00 |