| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,208 |
1,192 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
447 |
174 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
725 |
712 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,390 |
1,366 |
$19K |
| D1351 |
Sealant - per tooth |
838 |
214 |
$14K |
| D0330 |
Panoramic radiographic image |
423 |
411 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
676 |
664 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,603 |
785 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
901 |
877 |
$7K |
| D0274 |
Bitewings - four radiographic images |
520 |
506 |
$7K |
| D0272 |
Bitewings - two radiographic images |
465 |
456 |
$6K |
| D1110 |
Prophylaxis - adult |
134 |
129 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
123 |
85 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$652.68 |