| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
233 |
227 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
401 |
394 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
293 |
291 |
$10K |
| D1110 |
Prophylaxis - adult |
166 |
164 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
51 |
$8K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
92 |
$5K |
| D1351 |
Sealant - per tooth |
97 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
85 |
85 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
58 |
39 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$238.68 |