| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
895 |
889 |
$48K |
| D1206 |
Topical application of fluoride varnish |
864 |
864 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
802 |
796 |
$26K |
| D1351 |
Sealant - per tooth |
924 |
219 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
253 |
164 |
$18K |
| D0272 |
Bitewings - two radiographic images |
494 |
494 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
681 |
678 |
$5K |
| D0603 |
|
465 |
465 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$3K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
134 |
128 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
461 |
461 |
$2K |
| D0274 |
Bitewings - four radiographic images |
128 |
128 |
$2K |
| D9920 |
|
42 |
41 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
37 |
32 |
$1K |
| D0240 |
|
74 |
74 |
$1K |
| D0602 |
|
74 |
74 |
$740.00 |