| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,436 |
2,436 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,053 |
2,053 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,522 |
2,522 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
198 |
$17K |
| D1351 |
Sealant - per tooth |
624 |
119 |
$10K |
| D0272 |
Bitewings - two radiographic images |
1,129 |
1,129 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
261 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
553 |
520 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
467 |
464 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
244 |
244 |
$1K |
| D0330 |
Panoramic radiographic image |
45 |
45 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$308.84 |