| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
803 |
570 |
$14K |
| D1120 |
Prophylaxis - child |
570 |
434 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
63 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
751 |
533 |
$9K |
| D1110 |
Prophylaxis - adult |
247 |
170 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
160 |
129 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
31 |
$3K |
| D0272 |
Bitewings - two radiographic images |
153 |
136 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
91 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$786.90 |
| D1351 |
Sealant - per tooth |
36 |
13 |
$388.57 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
12 |
$315.27 |