| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,031 |
995 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,053 |
1,014 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
309 |
179 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
972 |
945 |
$14K |
| D1351 |
Sealant - per tooth |
376 |
150 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
256 |
232 |
$6K |
| D0272 |
Bitewings - two radiographic images |
492 |
484 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
29 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$784.99 |
| D0274 |
Bitewings - four radiographic images |
39 |
38 |
$627.08 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
24 |
$519.34 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$316.20 |
| D1206 |
Topical application of fluoride varnish |
14 |
12 |
$165.00 |
| D0240 |
|
15 |
12 |
$132.00 |