| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,338 |
2,287 |
$44K |
| D1354 |
|
4,017 |
1,018 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
2,966 |
2,909 |
$37K |
| D1206 |
Topical application of fluoride varnish |
3,054 |
2,992 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
988 |
577 |
$16K |
| D1110 |
Prophylaxis - adult |
720 |
709 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
557 |
330 |
$10K |
| D0272 |
Bitewings - two radiographic images |
988 |
971 |
$10K |
| D0274 |
Bitewings - four radiographic images |
227 |
225 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
137 |
125 |
$638.16 |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
86 |
$0.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
25 |
$0.00 |
| D1351 |
Sealant - per tooth |
118 |
49 |
$0.00 |