| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
535 |
535 |
$21K |
| D1206 |
Topical application of fluoride varnish |
674 |
674 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
547 |
547 |
$16K |
| D0272 |
Bitewings - two radiographic images |
307 |
307 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
125 |
$8K |
| D0274 |
Bitewings - four radiographic images |
191 |
191 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
29 |
$6K |
| D1351 |
Sealant - per tooth |
172 |
52 |
$6K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
188 |
186 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
131 |
123 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
20 |
19 |
$865.54 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$240.60 |
| D0603 |
|
486 |
486 |
$0.58 |
| D0601 |
|
48 |
48 |
$0.12 |
| D0602 |
|
15 |
15 |
$0.04 |