| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,108 |
1,102 |
$49K |
| D1120 |
Prophylaxis - child |
750 |
749 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,212 |
1,210 |
$30K |
| D1351 |
Sealant - per tooth |
1,115 |
159 |
$22K |
| D1206 |
Topical application of fluoride varnish |
572 |
571 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
539 |
539 |
$13K |
| D0274 |
Bitewings - four radiographic images |
510 |
508 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
49 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
109 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
788 |
782 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
143 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
530 |
524 |
$3K |
| D0603 |
|
238 |
237 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
38 |
$2K |
| D0272 |
Bitewings - two radiographic images |
63 |
62 |
$618.13 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
20 |
16 |
$495.00 |