| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,377 |
2,372 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
945 |
944 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
685 |
685 |
$45K |
| D1206 |
Topical application of fluoride varnish |
2,173 |
2,168 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,407 |
2,219 |
$31K |
| D0350 |
|
1,650 |
501 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
233 |
181 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
368 |
347 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
176 |
176 |
$8K |
| D0272 |
Bitewings - two radiographic images |
475 |
475 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
363 |
358 |
$4K |
| D1351 |
Sealant - per tooth |
101 |
48 |
$3K |
| D0274 |
Bitewings - four radiographic images |
141 |
140 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
27 |
$2K |
| D1320 |
|
58 |
58 |
$932.50 |
| D1999 |
|
1,791 |
1,753 |
$475.00 |