| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,014 |
1,013 |
$46K |
| D1206 |
Topical application of fluoride varnish |
999 |
998 |
$31K |
| D1351 |
Sealant - per tooth |
827 |
169 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
645 |
645 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
275 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
226 |
215 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
40 |
$5K |
| D0272 |
Bitewings - two radiographic images |
512 |
511 |
$5K |
| D0602 |
|
381 |
381 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
67 |
$3K |
| D0603 |
|
225 |
225 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
376 |
375 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
247 |
246 |
$792.00 |