| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,286 |
1,269 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,353 |
1,336 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,059 |
1,044 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
194 |
101 |
$12K |
| D0272 |
Bitewings - two radiographic images |
438 |
434 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
177 |
166 |
$4K |
| D1206 |
Topical application of fluoride varnish |
94 |
92 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
41 |
$1K |
| D1351 |
Sealant - per tooth |
46 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$904.00 |
| D1999 |
|
153 |
142 |
$693.00 |
| D0603 |
|
65 |
65 |
$671.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$482.00 |
| D0601 |
|
13 |
13 |
$110.00 |
| D1330 |
|
148 |
144 |
$0.00 |