| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
690 |
661 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
754 |
729 |
$15K |
| D1351 |
Sealant - per tooth |
611 |
83 |
$14K |
| D1206 |
Topical application of fluoride varnish |
816 |
782 |
$13K |
| D0272 |
Bitewings - two radiographic images |
395 |
373 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
582 |
213 |
$6K |
| D0274 |
Bitewings - four radiographic images |
200 |
191 |
$5K |
| D1110 |
Prophylaxis - adult |
126 |
118 |
$4K |
| D0330 |
Panoramic radiographic image |
137 |
122 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
301 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
127 |
124 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
26 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
57 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |