| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,673 |
4,403 |
$100K |
| D1351 |
Sealant - per tooth |
4,938 |
1,044 |
$100K |
| D1206 |
Topical application of fluoride varnish |
5,886 |
5,539 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
5,630 |
5,305 |
$84K |
| D0272 |
Bitewings - two radiographic images |
3,115 |
2,943 |
$54K |
| D1354 |
|
530 |
175 |
$43K |
| D1110 |
Prophylaxis - adult |
1,212 |
1,141 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,529 |
1,346 |
$35K |
| D0330 |
Panoramic radiographic image |
338 |
316 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
279 |
183 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
330 |
295 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
43 |
$2K |
| D0250 |
|
32 |
28 |
$532.50 |
| D0140 |
Limited oral evaluation - problem focused |
79 |
69 |
$519.12 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
25 |
$497.00 |
| D0240 |
|
19 |
13 |
$0.00 |