| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
423 |
330 |
$9K |
| D1351 |
Sealant - per tooth |
541 |
124 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
247 |
188 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
853 |
361 |
$4K |
| D1206 |
Topical application of fluoride varnish |
199 |
151 |
$3K |
| D0274 |
Bitewings - four radiographic images |
315 |
235 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
415 |
341 |
$3K |
| D3120 |
|
269 |
93 |
$2K |
| D2140 |
|
55 |
27 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
86 |
38 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
264 |
175 |
$2K |
| D1353 |
|
163 |
57 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
93 |
$1K |
| D4346 |
|
16 |
13 |
$1K |
| D2950 |
|
14 |
14 |
$983.92 |
| D0272 |
Bitewings - two radiographic images |
68 |
55 |
$721.14 |
| D0120 |
Periodic oral evaluation - established patient |
119 |
103 |
$631.56 |
| D9215 |
|
263 |
159 |
$565.80 |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
47 |
$241.32 |