| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,307 |
6,288 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
7,953 |
7,914 |
$17K |
| D1206 |
Topical application of fluoride varnish |
7,067 |
7,030 |
$13K |
| D1110 |
Prophylaxis - adult |
1,619 |
1,598 |
$9K |
| D0272 |
Bitewings - two radiographic images |
2,442 |
2,432 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
161 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,020 |
1,013 |
$3K |
| D1351 |
Sealant - per tooth |
1,384 |
481 |
$2K |
| D0330 |
Panoramic radiographic image |
287 |
287 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
98 |
$507.67 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
169 |
146 |
$233.69 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$70.84 |
| D0240 |
|
16 |
12 |
$56.06 |
| D1208 |
Topical application of fluoride, excluding varnish |
982 |
982 |
$13.00 |
| D1999 |
|
1,314 |
1,265 |
$0.00 |
| D0602 |
|
75 |
75 |
$0.00 |