| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,049 |
3,956 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
4,364 |
4,264 |
$122K |
| D1206 |
Topical application of fluoride varnish |
4,542 |
4,430 |
$109K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
231 |
148 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,452 |
1,421 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
818 |
762 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
170 |
$9K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$3K |
| D1330 |
|
422 |
414 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
43 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$697.80 |
| D0240 |
|
26 |
25 |
$396.00 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
29 |
$252.00 |