| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
627 |
604 |
$23K |
| D1206 |
Topical application of fluoride varnish |
526 |
512 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
339 |
332 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
236 |
218 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
635 |
270 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
121 |
111 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
348 |
332 |
$3K |
| D1351 |
Sealant - per tooth |
74 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
55 |
47 |
$940.38 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$480.02 |