| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
517 |
506 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
499 |
486 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
258 |
224 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
241 |
236 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
416 |
399 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
408 |
333 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
135 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
28 |
$3K |
| D0274 |
Bitewings - four radiographic images |
80 |
79 |
$2K |
| D1351 |
Sealant - per tooth |
51 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
55 |
55 |
$1K |
| D1206 |
Topical application of fluoride varnish |
34 |
29 |
$493.00 |