| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
873 |
764 |
$20K |
| D1120 |
Prophylaxis - child |
720 |
627 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
904 |
791 |
$14K |
| D1110 |
Prophylaxis - adult |
291 |
263 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
192 |
157 |
$8K |
| D0240 |
|
444 |
222 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
28 |
$5K |
| D0272 |
Bitewings - two radiographic images |
258 |
234 |
$4K |
| D0274 |
Bitewings - four radiographic images |
116 |
109 |
$4K |
| D1351 |
Sealant - per tooth |
143 |
34 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
53 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
139 |
$2K |
| D0330 |
Panoramic radiographic image |
40 |
31 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
30 |
$779.96 |
| D0145 |
Oral evaluation for a patient under three years of age |
23 |
16 |
$570.15 |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$486.62 |