| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,044 |
2,021 |
$92K |
| D1206 |
Topical application of fluoride varnish |
2,419 |
2,393 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,924 |
1,911 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
229 |
157 |
$31K |
| D1351 |
Sealant - per tooth |
529 |
109 |
$18K |
| D0272 |
Bitewings - two radiographic images |
488 |
480 |
$8K |
| D0274 |
Bitewings - four radiographic images |
242 |
242 |
$6K |
| D1330 |
|
789 |
775 |
$5K |
| D3120 |
|
151 |
98 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
78 |
$4K |
| D1110 |
Prophylaxis - adult |
60 |
60 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
211 |
200 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$141.84 |