| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,015 |
4,950 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
5,338 |
5,264 |
$95K |
| D1206 |
Topical application of fluoride varnish |
4,650 |
4,573 |
$83K |
| D0272 |
Bitewings - two radiographic images |
1,762 |
1,737 |
$31K |
| D1110 |
Prophylaxis - adult |
705 |
692 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,237 |
1,237 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
422 |
422 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
53 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
208 |
193 |
$7K |
| D0330 |
Panoramic radiographic image |
122 |
122 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
546 |
546 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
524 |
522 |
$6K |
| D1351 |
Sealant - per tooth |
104 |
30 |
$2K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$833.52 |