| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,344 |
1,222 |
$68K |
| D0240 |
|
1,381 |
1,094 |
$67K |
| D1120 |
Prophylaxis - child |
2,319 |
2,137 |
$39K |
| D0330 |
Panoramic radiographic image |
431 |
371 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
426 |
416 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
3,196 |
2,908 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
166 |
$15K |
| D0274 |
Bitewings - four radiographic images |
1,521 |
1,422 |
$7K |
| D1351 |
Sealant - per tooth |
2,055 |
474 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
25 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,705 |
3,408 |
$907.95 |
| D0220 |
Intraoral - periapical first radiographic image |
1,720 |
1,609 |
$750.47 |
| D0272 |
Bitewings - two radiographic images |
1,240 |
1,125 |
$165.01 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,603 |
1,503 |
$118.39 |
| D1330 |
|
3,822 |
3,514 |
$83.22 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
25 |
$52.00 |