| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,101 |
3,101 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
888 |
518 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
4,025 |
4,025 |
$84K |
| D1206 |
Topical application of fluoride varnish |
3,802 |
3,802 |
$72K |
| D1110 |
Prophylaxis - adult |
1,147 |
1,147 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
2,354 |
2,340 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
350 |
245 |
$29K |
| D0272 |
Bitewings - two radiographic images |
912 |
912 |
$16K |
| D0274 |
Bitewings - four radiographic images |
665 |
665 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,211 |
2,144 |
$15K |
| D1351 |
Sealant - per tooth |
134 |
42 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
27 |
$0.00 |