| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
639 |
637 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
616 |
616 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
113 |
$12K |
| D1206 |
Topical application of fluoride varnish |
453 |
452 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
407 |
400 |
$7K |
| D1351 |
Sealant - per tooth |
106 |
48 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
350 |
347 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
193 |
193 |
$2K |
| D0272 |
Bitewings - two radiographic images |
128 |
128 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
59 |
58 |
$1K |
| D7111 |
|
34 |
30 |
$994.89 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$374.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.31 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$216.66 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$151.45 |