| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,356 |
1,342 |
$59K |
| D1206 |
Topical application of fluoride varnish |
2,055 |
2,033 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,525 |
1,509 |
$45K |
| D8670 |
Periodic orthodontic treatment visit |
393 |
376 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
200 |
101 |
$24K |
| D1110 |
Prophylaxis - adult |
304 |
299 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
147 |
$8K |
| D0274 |
Bitewings - four radiographic images |
165 |
162 |
$4K |
| D8660 |
|
26 |
24 |
$4K |
| D1330 |
|
471 |
458 |
$3K |
| D1351 |
Sealant - per tooth |
80 |
15 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
147 |
126 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
17 |
$2K |
| D0272 |
Bitewings - two radiographic images |
131 |
130 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
22 |
22 |
$506.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$141.84 |