| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,643 |
1,643 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
465 |
365 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,932 |
1,932 |
$61K |
| D1206 |
Topical application of fluoride varnish |
2,133 |
2,133 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
393 |
304 |
$42K |
| D1351 |
Sealant - per tooth |
852 |
414 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,348 |
1,267 |
$26K |
| D1110 |
Prophylaxis - adult |
356 |
356 |
$24K |
| D0272 |
Bitewings - two radiographic images |
685 |
685 |
$11K |
| D0330 |
Panoramic radiographic image |
106 |
106 |
$5K |
| D0274 |
Bitewings - four radiographic images |
97 |
97 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
81 |
$933.78 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$732.42 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$614.38 |