| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,291 |
2,288 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
1,798 |
1,794 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
310 |
310 |
$22K |
| D1206 |
Topical application of fluoride varnish |
2,505 |
2,500 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
44 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
317 |
288 |
$7K |
| D1330 |
|
2,450 |
2,444 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,246 |
486 |
$5K |
| D0272 |
Bitewings - two radiographic images |
801 |
800 |
$4K |
| D0240 |
|
907 |
498 |
$3K |
| D1351 |
Sealant - per tooth |
124 |
30 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
732 |
685 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$441.45 |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$432.04 |