| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,251 |
2,251 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
3,419 |
3,418 |
$85K |
| D1110 |
Prophylaxis - adult |
1,475 |
1,474 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,614 |
3,611 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
736 |
439 |
$46K |
| D0274 |
Bitewings - four radiographic images |
714 |
714 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,014 |
1,014 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
186 |
$4K |
| D0330 |
Panoramic radiographic image |
109 |
109 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
31 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
250 |
250 |
$2K |
| D1351 |
Sealant - per tooth |
44 |
13 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
48 |
33 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
120 |
120 |
$806.34 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$160.87 |
| D1999 |
|
183 |
167 |
$0.00 |