| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,346 |
1,346 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
597 |
368 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
800 |
800 |
$43K |
| D0274 |
Bitewings - four radiographic images |
582 |
582 |
$28K |
| D1110 |
Prophylaxis - adult |
549 |
549 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
95 |
95 |
$20K |
| D0330 |
Panoramic radiographic image |
294 |
294 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
308 |
221 |
$16K |
| D1351 |
Sealant - per tooth |
2,734 |
496 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
18 |
18 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
980 |
980 |
$300.56 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
678 |
571 |
$94.05 |
| D0272 |
Bitewings - two radiographic images |
420 |
420 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,935 |
1,472 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
1,885 |
1,885 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,561 |
1,550 |
$0.00 |