| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,323 |
2,301 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
2,842 |
2,813 |
$83K |
| D1110 |
Prophylaxis - adult |
583 |
581 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,237 |
1,225 |
$28K |
| D1206 |
Topical application of fluoride varnish |
950 |
945 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
56 |
$9K |
| D0330 |
Panoramic radiographic image |
196 |
192 |
$8K |
| D1351 |
Sealant - per tooth |
130 |
25 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
27 |
$5K |
| D1330 |
|
685 |
678 |
$4K |
| D0272 |
Bitewings - two radiographic images |
149 |
146 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
36 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
17 |
$927.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
25 |
$511.94 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$336.98 |