| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,274 |
1,271 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
685 |
684 |
$27K |
| D0330 |
Panoramic radiographic image |
427 |
426 |
$26K |
| D1110 |
Prophylaxis - adult |
265 |
265 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
99 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
137 |
93 |
$7K |
| D1351 |
Sealant - per tooth |
516 |
141 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
878 |
876 |
$4K |
| D1330 |
|
1,701 |
1,698 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
330 |
303 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
98 |
98 |
$2K |
| D7111 |
|
18 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
241 |
241 |
$996.00 |
| D0220 |
Intraoral - periapical first radiographic image |
407 |
397 |
$329.08 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$238.00 |
| D0272 |
Bitewings - two radiographic images |
852 |
851 |
$117.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
373 |
268 |
$87.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
190 |
187 |
$74.00 |
| D1206 |
Topical application of fluoride varnish |
1,478 |
1,478 |
$56.60 |
| D3120 |
|
18 |
13 |
$0.00 |