| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
696 |
688 |
$20K |
| D1351 |
Sealant - per tooth |
795 |
277 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
936 |
924 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,040 |
1,029 |
$17K |
| D1110 |
Prophylaxis - adult |
366 |
361 |
$14K |
| D0272 |
Bitewings - two radiographic images |
540 |
535 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
115 |
$10K |
| D0274 |
Bitewings - four radiographic images |
361 |
354 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
30 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
140 |
120 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
45 |
$1K |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$381.55 |
| D0220 |
Intraoral - periapical first radiographic image |
35 |
32 |
$360.00 |