| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,379 |
1,352 |
$29K |
| D0274 |
Bitewings - four radiographic images |
912 |
898 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
231 |
230 |
$14K |
| D1110 |
Prophylaxis - adult |
222 |
222 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
75 |
$6K |
| D1206 |
Topical application of fluoride varnish |
1,713 |
1,673 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
1,165 |
1,141 |
$5K |
| D1330 |
|
1,762 |
1,732 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
249 |
207 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
399 |
250 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
601 |
519 |
$453.97 |
| D1351 |
Sealant - per tooth |
67 |
14 |
$358.25 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$186.40 |
| D0272 |
Bitewings - two radiographic images |
83 |
83 |
$164.44 |
| D0145 |
Oral evaluation for a patient under three years of age |
49 |
49 |
$112.00 |