| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,390 |
1,375 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,950 |
1,930 |
$23K |
| D1110 |
Prophylaxis - adult |
530 |
525 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
1,361 |
1,347 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
384 |
379 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
337 |
300 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
56 |
$9K |
| D0274 |
Bitewings - four radiographic images |
242 |
241 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
427 |
419 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
388 |
327 |
$5K |
| D0272 |
Bitewings - two radiographic images |
347 |
342 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
31 |
$4K |
| D1351 |
Sealant - per tooth |
253 |
80 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$451.92 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$0.00 |
| D9994 |
|
423 |
420 |
$0.00 |
| D0240 |
|
148 |
77 |
$0.00 |
| D9630 |
|
226 |
226 |
$0.00 |