| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,299 |
4,295 |
$193K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,755 |
749 |
$174K |
| D1120 |
Prophylaxis - child |
3,686 |
3,684 |
$165K |
| D1206 |
Topical application of fluoride varnish |
4,123 |
4,121 |
$127K |
| D0272 |
Bitewings - two radiographic images |
934 |
934 |
$32K |
| D1110 |
Prophylaxis - adult |
596 |
587 |
$27K |
| D0274 |
Bitewings - four radiographic images |
668 |
664 |
$22K |
| D1351 |
Sealant - per tooth |
98 |
26 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
147 |
144 |
$4K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
65 |
$970.00 |