| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,858 |
2,858 |
$120K |
| D0120 |
Periodic oral evaluation - established patient |
2,812 |
2,812 |
$80K |
| D1206 |
Topical application of fluoride varnish |
1,956 |
1,955 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
441 |
239 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
1,979 |
1,961 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,462 |
1,461 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,110 |
1,110 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,644 |
1,641 |
$13K |
| D1351 |
Sealant - per tooth |
307 |
87 |
$12K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
226 |
226 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
35 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
68 |
$938.56 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$507.20 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$396.72 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
38 |
$0.00 |