| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,896 |
3,863 |
$130K |
| D1206 |
Topical application of fluoride varnish |
5,325 |
5,272 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
5,077 |
5,022 |
$101K |
| D1110 |
Prophylaxis - adult |
835 |
823 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
330 |
168 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,120 |
1,106 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
547 |
502 |
$19K |
| D0274 |
Bitewings - four radiographic images |
300 |
300 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
37 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
131 |
131 |
$4K |
| D1351 |
Sealant - per tooth |
92 |
37 |
$3K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$647.88 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
51 |
$570.18 |
| D3120 |
|
27 |
13 |
$497.07 |