| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,215 |
3,209 |
$140K |
| D1206 |
Topical application of fluoride varnish |
3,243 |
3,236 |
$100K |
| D1351 |
Sealant - per tooth |
4,940 |
1,242 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,995 |
2,988 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
465 |
308 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,040 |
1,023 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
298 |
201 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,569 |
1,569 |
$16K |
| D1353 |
|
1,610 |
365 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
2,152 |
2,143 |
$11K |
| D0603 |
|
1,017 |
1,010 |
$8K |
| D0274 |
Bitewings - four radiographic images |
499 |
493 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,812 |
1,804 |
$6K |
| D1110 |
Prophylaxis - adult |
86 |
86 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
139 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
15 |
13 |
$3K |
| D0601 |
|
326 |
326 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
132 |
131 |
$2K |