| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,145 |
2,130 |
$75K |
| D1351 |
Sealant - per tooth |
2,700 |
617 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,586 |
2,566 |
$72K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,897 |
2,878 |
$42K |
| D1110 |
Prophylaxis - adult |
656 |
655 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,429 |
1,421 |
$33K |
| D0274 |
Bitewings - four radiographic images |
691 |
690 |
$23K |
| D0145 |
Oral evaluation for a patient under three years of age |
130 |
129 |
$18K |
| D0240 |
|
1,793 |
831 |
$15K |
| D0330 |
Panoramic radiographic image |
233 |
233 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
710 |
700 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
570 |
468 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
44 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
186 |
178 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
25 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
65 |
$1K |
| D0601 |
|
1,644 |
1,633 |
$0.00 |
| D0603 |
|
764 |
758 |
$0.00 |
| D0602 |
|
682 |
679 |
$0.00 |