| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,572 |
1,406 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
2,884 |
2,633 |
$48K |
| D1120 |
Prophylaxis - child |
1,488 |
1,364 |
$37K |
| D0330 |
Panoramic radiographic image |
756 |
680 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,304 |
2,121 |
$29K |
| D1999 |
|
1,603 |
1,384 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,060 |
940 |
$19K |
| D0272 |
Bitewings - two radiographic images |
595 |
556 |
$9K |
| D1206 |
Topical application of fluoride varnish |
403 |
345 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
55 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
391 |
312 |
$3K |
| D1351 |
Sealant - per tooth |
193 |
27 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
253 |
145 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
43 |
$902.00 |
| D0140 |
Limited oral evaluation - problem focused |
33 |
31 |
$754.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
27 |
$554.00 |