| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
400 |
378 |
$10K |
| D1120 |
Prophylaxis - child |
314 |
300 |
$9K |
| D0274 |
Bitewings - four radiographic images |
175 |
159 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
443 |
155 |
$3K |
| D1351 |
Sealant - per tooth |
138 |
24 |
$3K |
| D1206 |
Topical application of fluoride varnish |
193 |
183 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
145 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
189 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
26 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
38 |
35 |
$945.74 |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$877.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
15 |
$241.92 |
| D0603 |
|
566 |
533 |
$0.01 |