| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,166 |
4,147 |
$251K |
| D1110 |
Prophylaxis - adult |
813 |
802 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
5,808 |
5,779 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
87 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$2K |
| D1351 |
Sealant - per tooth |
316 |
50 |
$958.98 |
| D0240 |
|
25 |
13 |
$381.07 |
| D0220 |
Intraoral - periapical first radiographic image |
536 |
516 |
$137.46 |
| D0272 |
Bitewings - two radiographic images |
1,514 |
1,507 |
$47.61 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
275 |
267 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
26 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,841 |
1,836 |
$-41.68 |
| D1206 |
Topical application of fluoride varnish |
2,793 |
2,778 |
$-533.86 |