| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
847 |
832 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,070 |
1,054 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,117 |
1,102 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
306 |
297 |
$17K |
| D1110 |
Prophylaxis - adult |
314 |
314 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
100 |
$10K |
| D0274 |
Bitewings - four radiographic images |
322 |
318 |
$10K |
| D1330 |
|
818 |
814 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
85 |
$7K |
| D0272 |
Bitewings - two radiographic images |
296 |
294 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$2K |
| D1351 |
Sealant - per tooth |
31 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
89 |
$869.60 |
| D0270 |
|
12 |
12 |
$118.00 |