| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,852 |
2,851 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
2,525 |
2,524 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,587 |
2,586 |
$65K |
| D0272 |
Bitewings - two radiographic images |
1,525 |
1,524 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
250 |
172 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
317 |
288 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,129 |
1,112 |
$8K |
| D1206 |
Topical application of fluoride varnish |
202 |
202 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
588 |
586 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
110 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
13 |
$1K |
| D1351 |
Sealant - per tooth |
43 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$749.60 |