| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,839 |
4,762 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
4,720 |
4,651 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
688 |
291 |
$21K |
| D0272 |
Bitewings - two radiographic images |
2,923 |
2,867 |
$19K |
| D1206 |
Topical application of fluoride varnish |
2,715 |
2,676 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,858 |
2,808 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
723 |
705 |
$10K |
| D0330 |
Panoramic radiographic image |
690 |
680 |
$10K |
| D1110 |
Prophylaxis - adult |
737 |
724 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
610 |
580 |
$5K |
| D1351 |
Sealant - per tooth |
296 |
79 |
$2K |
| D0274 |
Bitewings - four radiographic images |
261 |
260 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
117 |
$527.19 |
| D0240 |
|
108 |
73 |
$489.23 |
| D0603 |
|
2,411 |
2,299 |
$0.00 |