| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,513 |
2,512 |
$81K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,176 |
3,174 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
2,803 |
2,801 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
449 |
257 |
$40K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,148 |
1,012 |
$38K |
| D9920 |
|
345 |
331 |
$23K |
| D0272 |
Bitewings - two radiographic images |
999 |
999 |
$19K |
| D1110 |
Prophylaxis - adult |
403 |
402 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,115 |
1,110 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,022 |
980 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
65 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
196 |
$6K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$4K |
| D1351 |
Sealant - per tooth |
79 |
39 |
$2K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$1K |
| D0240 |
|
104 |
52 |
$1K |
| D1999 |
|
20 |
20 |
$0.00 |