| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,535 |
2,506 |
$89K |
| D1110 |
Prophylaxis - adult |
511 |
494 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
2,829 |
2,793 |
$12K |
| D1206 |
Topical application of fluoride varnish |
3,247 |
3,207 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
162 |
$5K |
| D1330 |
|
2,116 |
2,091 |
$5K |
| D0272 |
Bitewings - two radiographic images |
1,328 |
1,313 |
$3K |
| D1351 |
Sealant - per tooth |
112 |
26 |
$820.00 |
| D0274 |
Bitewings - four radiographic images |
119 |
114 |
$706.06 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$323.96 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$179.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$165.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
27 |
$83.60 |
| D0220 |
Intraoral - periapical first radiographic image |
269 |
263 |
$46.88 |
| D9987 |
|
13 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
184 |
180 |
$0.00 |