| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
542 |
491 |
$21K |
| D1206 |
Topical application of fluoride varnish |
545 |
493 |
$17K |
| D1351 |
Sealant - per tooth |
525 |
107 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
234 |
207 |
$6K |
| D0274 |
Bitewings - four radiographic images |
280 |
250 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
479 |
440 |
$4K |
| D0350 |
|
477 |
430 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
218 |
209 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
35 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
461 |
418 |
$2K |
| D0603 |
|
350 |
323 |
$1K |
| D0330 |
Panoramic radiographic image |
35 |
33 |
$1K |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$900.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
31 |
$590.08 |
| D0602 |
|
61 |
60 |
$220.00 |