| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
960 |
950 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
1,186 |
1,174 |
$14K |
| D1206 |
Topical application of fluoride varnish |
1,208 |
1,195 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
219 |
141 |
$8K |
| D1110 |
Prophylaxis - adult |
226 |
223 |
$5K |
| D1354 |
|
1,586 |
344 |
$4K |
| D0272 |
Bitewings - two radiographic images |
375 |
370 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
55 |
$2K |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$0.00 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$0.00 |
| D0603 |
|
460 |
456 |
$0.00 |
| D1351 |
Sealant - per tooth |
82 |
41 |
$0.00 |
| D0602 |
|
201 |
200 |
$0.00 |
| D0601 |
|
39 |
39 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$0.00 |