| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,216 |
628 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,277 |
654 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,383 |
695 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
223 |
65 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
81 |
$10K |
| D0272 |
Bitewings - two radiographic images |
287 |
141 |
$4K |
| D1351 |
Sealant - per tooth |
184 |
29 |
$3K |
| D1354 |
|
568 |
72 |
$3K |
| D1110 |
Prophylaxis - adult |
232 |
117 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
40 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
61 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
49 |
30 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
71 |
41 |
$918.14 |
| D0274 |
Bitewings - four radiographic images |
26 |
14 |
$564.48 |
| D9920 |
|
17 |
12 |
$140.49 |