| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
759 |
747 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
397 |
216 |
$26K |
| D1110 |
Prophylaxis - adult |
489 |
479 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
872 |
866 |
$22K |
| D1351 |
Sealant - per tooth |
1,014 |
204 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
442 |
432 |
$16K |
| D1206 |
Topical application of fluoride varnish |
701 |
695 |
$13K |
| D0274 |
Bitewings - four radiographic images |
586 |
573 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,003 |
936 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
67 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
72 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
710 |
642 |
$3K |
| D9920 |
|
66 |
61 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
70 |
64 |
$1K |
| D0416 |
|
38 |
38 |
$296.00 |