| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
194 |
194 |
$39K |
| D1120 |
Prophylaxis - child |
615 |
601 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
448 |
448 |
$17K |
| D1206 |
Topical application of fluoride varnish |
578 |
564 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
176 |
166 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
109 |
$3K |
| D0272 |
Bitewings - two radiographic images |
120 |
120 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$2K |
| D9920 |
|
17 |
17 |
$2K |
| D0603 |
|
82 |
82 |
$780.18 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$400.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$353.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
138 |
73 |
$345.00 |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
75 |
$321.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$136.00 |