| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,365 |
1,359 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,478 |
1,478 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,509 |
1,505 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
200 |
130 |
$16K |
| D0274 |
Bitewings - four radiographic images |
390 |
390 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
536 |
533 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
204 |
194 |
$5K |
| D0272 |
Bitewings - two radiographic images |
257 |
257 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
305 |
276 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
40 |
$4K |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$3K |
| D1351 |
Sealant - per tooth |
75 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
51 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$854.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$843.80 |
| D0603 |
|
50 |
50 |
$504.00 |
| D0602 |
|
12 |
12 |
$120.00 |