| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
915 |
865 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,061 |
1,006 |
$21K |
| D1351 |
Sealant - per tooth |
831 |
101 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,112 |
1,048 |
$17K |
| D0272 |
Bitewings - two radiographic images |
552 |
526 |
$10K |
| D0274 |
Bitewings - four radiographic images |
303 |
280 |
$8K |
| D1110 |
Prophylaxis - adult |
204 |
193 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
668 |
237 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
53 |
$5K |
| D0330 |
Panoramic radiographic image |
188 |
158 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
362 |
335 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
130 |
127 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$790.00 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
16 |
$433.90 |