| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,660 |
3,638 |
$176K |
| D0120 |
Periodic oral evaluation - established patient |
3,855 |
3,830 |
$128K |
| D1206 |
Topical application of fluoride varnish |
1,875 |
1,872 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,735 |
1,731 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
560 |
393 |
$45K |
| D0272 |
Bitewings - two radiographic images |
2,566 |
2,560 |
$38K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
883 |
782 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,662 |
2,644 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,231 |
2,226 |
$12K |
| D0274 |
Bitewings - four radiographic images |
500 |
499 |
$8K |
| D0603 |
|
763 |
763 |
$8K |
| D1351 |
Sealant - per tooth |
254 |
38 |
$7K |
| D0602 |
|
513 |
513 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
79 |
$5K |
| D1110 |
Prophylaxis - adult |
27 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$750.00 |