| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
802 |
763 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,387 |
1,328 |
$33K |
| D1120 |
Prophylaxis - child |
971 |
928 |
$32K |
| D0330 |
Panoramic radiographic image |
684 |
653 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,436 |
1,380 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
552 |
524 |
$16K |
| D2740 |
Crown - porcelain/ceramic |
18 |
13 |
$10K |
| D0274 |
Bitewings - four radiographic images |
293 |
279 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
140 |
121 |
$4K |
| D1351 |
Sealant - per tooth |
98 |
28 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
83 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$166.53 |