| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,239 |
1,235 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,368 |
1,363 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
1,200 |
1,195 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
455 |
424 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
172 |
103 |
$6K |
| D0272 |
Bitewings - two radiographic images |
530 |
527 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
154 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
308 |
306 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
39 |
$2K |
| D1110 |
Prophylaxis - adult |
91 |
91 |
$858.90 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
38 |
$451.92 |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$430.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
25 |
$232.48 |
| D1351 |
Sealant - per tooth |
164 |
50 |
$0.00 |