| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,529 |
2,528 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
3,023 |
3,020 |
$80K |
| D1206 |
Topical application of fluoride varnish |
2,982 |
2,981 |
$71K |
| D1110 |
Prophylaxis - adult |
536 |
535 |
$26K |
| D0272 |
Bitewings - two radiographic images |
838 |
837 |
$19K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
193 |
126 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
84 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
48 |
$8K |
| D0274 |
Bitewings - four radiographic images |
133 |
133 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$2K |
| D2140 |
|
26 |
16 |
$1K |
| D1351 |
Sealant - per tooth |
46 |
17 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$126.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
63 |
57 |
$0.00 |