| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,157 |
1,150 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
985 |
980 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
792 |
785 |
$21K |
| D1351 |
Sealant - per tooth |
259 |
109 |
$14K |
| D0274 |
Bitewings - four radiographic images |
406 |
403 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
42 |
$5K |
| D1206 |
Topical application of fluoride varnish |
176 |
175 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
132 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
523 |
512 |
$3K |
| D0330 |
Panoramic radiographic image |
84 |
84 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
458 |
449 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
19 |
$910.00 |
| D0272 |
Bitewings - two radiographic images |
84 |
84 |
$861.45 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$837.20 |