| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
553 |
530 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
902 |
878 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
748 |
724 |
$20K |
| D1110 |
Prophylaxis - adult |
195 |
191 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
150 |
134 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
33 |
$6K |
| D0272 |
Bitewings - two radiographic images |
186 |
177 |
$5K |
| D1351 |
Sealant - per tooth |
145 |
22 |
$5K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$507.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$482.00 |
| D1320 |
|
14 |
14 |
$455.91 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$214.50 |