| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,082 |
3,067 |
$65K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,218 |
3,201 |
$49K |
| D1120 |
Prophylaxis - child |
2,171 |
2,161 |
$44K |
| D1110 |
Prophylaxis - adult |
574 |
573 |
$18K |
| D0272 |
Bitewings - two radiographic images |
793 |
791 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
268 |
166 |
$11K |
| D1351 |
Sealant - per tooth |
421 |
131 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
605 |
496 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
42 |
$2K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
37 |
$435.11 |