| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,959 |
1,959 |
$53K |
| D1206 |
Topical application of fluoride varnish |
2,030 |
2,013 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,968 |
1,968 |
$45K |
| D0272 |
Bitewings - two radiographic images |
1,447 |
1,446 |
$17K |
| D0240 |
|
2,139 |
1,078 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
182 |
120 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
416 |
384 |
$12K |
| D1999 |
|
1,155 |
1,107 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
155 |
155 |
$7K |
| D1351 |
Sealant - per tooth |
97 |
25 |
$2K |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
197 |
193 |
$981.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
146 |
142 |
$582.78 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$340.38 |
| D0330 |
Panoramic radiographic image |
226 |
226 |
$118.46 |