| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
743 |
743 |
$160K |
| D1120 |
Prophylaxis - child |
2,244 |
2,241 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
1,762 |
1,762 |
$76K |
| D1206 |
Topical application of fluoride varnish |
2,330 |
2,329 |
$68K |
| D0272 |
Bitewings - two radiographic images |
404 |
404 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
56 |
$9K |
| D1351 |
Sealant - per tooth |
80 |
24 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
178 |
170 |
$4K |
| D1110 |
Prophylaxis - adult |
86 |
86 |
$3K |
| D0274 |
Bitewings - four radiographic images |
66 |
66 |
$2K |
| D9420 |
|
13 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$2K |
| D0191 |
|
130 |
130 |
$1K |
| D9920 |
|
15 |
15 |
$1K |
| D9410 |
|
14 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$1K |