| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,281 |
1,278 |
$68K |
| D1206 |
Topical application of fluoride varnish |
1,928 |
1,909 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,752 |
1,746 |
$55K |
| D1110 |
Prophylaxis - adult |
703 |
697 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
207 |
113 |
$27K |
| D0272 |
Bitewings - two radiographic images |
586 |
585 |
$13K |
| D0274 |
Bitewings - four radiographic images |
385 |
385 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
338 |
329 |
$11K |
| D0330 |
Panoramic radiographic image |
155 |
155 |
$9K |
| D1351 |
Sealant - per tooth |
216 |
72 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
151 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
233 |
231 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
43 |
$1K |