| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2394 |
|
763 |
391 |
$111K |
| D1120 |
Prophylaxis - child |
2,607 |
2,599 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
2,200 |
2,193 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,264 |
1,262 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,332 |
2,325 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,341 |
2,330 |
$26K |
| D1351 |
Sealant - per tooth |
448 |
171 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
598 |
597 |
$14K |
| D0274 |
Bitewings - four radiographic images |
595 |
595 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,018 |
1,017 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,084 |
1,084 |
$13K |
| D1110 |
Prophylaxis - adult |
155 |
155 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
53 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
96 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$360.00 |