| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,095 |
1,091 |
$27K |
| D1120 |
Prophylaxis - child |
617 |
616 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
225 |
185 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
939 |
934 |
$18K |
| D1110 |
Prophylaxis - adult |
348 |
345 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
324 |
318 |
$15K |
| D1351 |
Sealant - per tooth |
355 |
71 |
$11K |
| D0272 |
Bitewings - two radiographic images |
426 |
424 |
$9K |
| D1330 |
|
907 |
902 |
$9K |
| D1310 |
|
929 |
924 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
171 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
36 |
$3K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$736.00 |
| D0603 |
|
28 |
27 |
$270.00 |
| D0602 |
|
12 |
12 |
$120.00 |