| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,724 |
3,718 |
$145K |
| D0120 |
Periodic oral evaluation - established patient |
4,167 |
4,164 |
$113K |
| D1206 |
Topical application of fluoride varnish |
3,875 |
3,871 |
$71K |
| D1110 |
Prophylaxis - adult |
678 |
677 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,407 |
1,405 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
286 |
153 |
$20K |
| D0330 |
Panoramic radiographic image |
205 |
205 |
$10K |
| D0274 |
Bitewings - four radiographic images |
314 |
314 |
$8K |
| D1351 |
Sealant - per tooth |
231 |
57 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
304 |
265 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
179 |
177 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
46 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$2K |
| D0603 |
|
12 |
12 |
$99.00 |