| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,825 |
3,528 |
$161K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,981 |
3,653 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
3,917 |
3,637 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
428 |
224 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,274 |
1,151 |
$31K |
| D1110 |
Prophylaxis - adult |
443 |
439 |
$27K |
| D1206 |
Topical application of fluoride varnish |
462 |
462 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
12 |
$6K |
| D0330 |
Panoramic radiographic image |
70 |
68 |
$4K |
| D0274 |
Bitewings - four radiographic images |
120 |
120 |
$4K |
| D1351 |
Sealant - per tooth |
95 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$810.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$785.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$390.00 |