| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,135 |
1,126 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,288 |
1,268 |
$34K |
| D1351 |
Sealant - per tooth |
997 |
183 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
860 |
843 |
$20K |
| D0272 |
Bitewings - two radiographic images |
560 |
558 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
166 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
30 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
147 |
138 |
$4K |
| D0603 |
|
263 |
263 |
$3K |
| D0240 |
|
168 |
101 |
$2K |
| D1110 |
Prophylaxis - adult |
48 |
44 |
$2K |
| D0602 |
|
180 |
180 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
299 |
298 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
169 |
164 |
$782.04 |
| D1330 |
|
133 |
133 |
$635.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
13 |
$459.48 |