| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,253 |
2,125 |
$65K |
| D1206 |
Topical application of fluoride varnish |
2,116 |
1,995 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,023 |
997 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
971 |
895 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
125 |
85 |
$17K |
| D0274 |
Bitewings - four radiographic images |
513 |
451 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
302 |
256 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
68 |
$10K |
| D1351 |
Sealant - per tooth |
376 |
67 |
$10K |
| D0272 |
Bitewings - two radiographic images |
277 |
270 |
$6K |
| D0330 |
Panoramic radiographic image |
93 |
77 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
14 |
$900.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
26 |
$780.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
26 |
$370.60 |
| D1999 |
|
495 |
457 |
$0.00 |