| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,028 |
3,005 |
$81K |
| D1206 |
Topical application of fluoride varnish |
3,741 |
3,701 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
3,182 |
3,152 |
$50K |
| D1110 |
Prophylaxis - adult |
686 |
673 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
310 |
176 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
539 |
529 |
$15K |
| D0272 |
Bitewings - two radiographic images |
886 |
875 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
406 |
375 |
$12K |
| D1351 |
Sealant - per tooth |
69 |
24 |
$2K |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$1K |
| D0240 |
|
72 |
38 |
$709.18 |
| D9630 |
|
14 |
14 |
$360.79 |