| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,166 |
1,144 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,686 |
1,631 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,462 |
1,422 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
349 |
334 |
$19K |
| D1110 |
Prophylaxis - adult |
300 |
287 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
86 |
$8K |
| D0274 |
Bitewings - four radiographic images |
236 |
227 |
$8K |
| D0272 |
Bitewings - two radiographic images |
274 |
274 |
$5K |
| D1351 |
Sealant - per tooth |
69 |
25 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
126 |
$1K |
| D0240 |
|
62 |
36 |
$810.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$730.00 |
| D1330 |
|
56 |
56 |
$430.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
15 |
$288.00 |