| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
480 |
468 |
$9K |
| D0274 |
Bitewings - four radiographic images |
482 |
468 |
$8K |
| D1120 |
Prophylaxis - child |
363 |
347 |
$6K |
| D1206 |
Topical application of fluoride varnish |
517 |
503 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
30 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
19 |
$2K |
| D1351 |
Sealant - per tooth |
67 |
24 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
12 |
$578.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
20 |
16 |
$460.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$148.00 |