| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,766 |
1,730 |
$81K |
| D1351 |
Sealant - per tooth |
2,179 |
371 |
$76K |
| D1206 |
Topical application of fluoride varnish |
2,745 |
2,681 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
1,512 |
1,476 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
225 |
$44K |
| D1110 |
Prophylaxis - adult |
560 |
543 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
648 |
630 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
697 |
612 |
$13K |
| D0272 |
Bitewings - two radiographic images |
809 |
790 |
$13K |
| D0330 |
Panoramic radiographic image |
249 |
244 |
$11K |
| D1330 |
|
1,314 |
1,275 |
$8K |
| D0274 |
Bitewings - four radiographic images |
260 |
247 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
24 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
44 |
$2K |
| D3120 |
|
24 |
16 |
$735.00 |
| D0240 |
|
24 |
24 |
$288.00 |