| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,165 |
1,004 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
488 |
208 |
$9K |
| D1206 |
Topical application of fluoride varnish |
1,301 |
1,121 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
758 |
653 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
489 |
425 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
77 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
488 |
330 |
$2K |
| D0330 |
Panoramic radiographic image |
112 |
93 |
$2K |
| D0272 |
Bitewings - two radiographic images |
258 |
223 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
324 |
275 |
$1K |
| D4346 |
|
27 |
27 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
186 |
70 |
$1K |
| D0350 |
|
233 |
176 |
$1K |
| D1351 |
Sealant - per tooth |
186 |
52 |
$1K |
| D1110 |
Prophylaxis - adult |
75 |
68 |
$571.30 |
| D0274 |
Bitewings - four radiographic images |
77 |
66 |
$546.44 |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$183.81 |
| D0602 |
|
784 |
615 |
$0.00 |
| D0603 |
|
13 |
12 |
$0.00 |