| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,705 |
1,694 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
650 |
342 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,142 |
2,118 |
$73K |
| D1206 |
Topical application of fluoride varnish |
2,592 |
2,564 |
$49K |
| D1110 |
Prophylaxis - adult |
398 |
390 |
$21K |
| D0272 |
Bitewings - two radiographic images |
565 |
561 |
$14K |
| D0274 |
Bitewings - four radiographic images |
199 |
186 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
108 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
65 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
262 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$3K |
| D1351 |
Sealant - per tooth |
131 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
26 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
39 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
12 |
$720.80 |