| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,528 |
2,173 |
$71K |
| D1206 |
Topical application of fluoride varnish |
2,562 |
2,206 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,947 |
1,751 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
280 |
145 |
$32K |
| D0330 |
Panoramic radiographic image |
714 |
596 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,109 |
931 |
$27K |
| D1351 |
Sealant - per tooth |
581 |
94 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
422 |
301 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
251 |
152 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
242 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
221 |
173 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |