| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,496 |
1,495 |
$80K |
| D1351 |
Sealant - per tooth |
2,224 |
453 |
$54K |
| D1206 |
Topical application of fluoride varnish |
1,525 |
1,524 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,289 |
1,289 |
$42K |
| D0272 |
Bitewings - two radiographic images |
804 |
804 |
$10K |
| D0603 |
|
1,511 |
1,509 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,265 |
1,265 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
54 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,097 |
1,093 |
$5K |
| D0274 |
Bitewings - four radiographic images |
337 |
337 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
105 |
104 |
$3K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$2K |
| D9920 |
|
27 |
27 |
$846.00 |