| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
862 |
862 |
$24K |
| D0274 |
Bitewings - four radiographic images |
830 |
830 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,545 |
1,545 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,179 |
1,179 |
$24K |
| D1110 |
Prophylaxis - adult |
355 |
355 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
882 |
858 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,178 |
586 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
263 |
233 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
220 |
$7K |
| D0330 |
Panoramic radiographic image |
122 |
122 |
$6K |
| D0350 |
|
43 |
43 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$854.00 |
| D1351 |
Sealant - per tooth |
31 |
12 |
$756.40 |