| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,926 |
1,785 |
$76K |
| D1206 |
Topical application of fluoride varnish |
2,236 |
2,087 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,824 |
1,699 |
$50K |
| D1351 |
Sealant - per tooth |
608 |
101 |
$13K |
| D0272 |
Bitewings - two radiographic images |
427 |
384 |
$6K |
| D1110 |
Prophylaxis - adult |
62 |
57 |
$3K |
| D1330 |
|
542 |
472 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
15 |
$3K |
| D0274 |
Bitewings - four radiographic images |
97 |
96 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$2K |
| D3120 |
|
20 |
12 |
$700.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$588.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
26 |
$558.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$216.00 |