| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
576 |
478 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,230 |
1,014 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
225 |
138 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,302 |
1,050 |
$23K |
| D1351 |
Sealant - per tooth |
386 |
42 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
304 |
234 |
$11K |
| D1120 |
Prophylaxis - child |
310 |
256 |
$11K |
| D0274 |
Bitewings - four radiographic images |
292 |
216 |
$10K |
| D0330 |
Panoramic radiographic image |
47 |
40 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
58 |
$968.00 |
| D1206 |
Topical application of fluoride varnish |
45 |
42 |
$924.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$500.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
22 |
14 |
$176.00 |