| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,618 |
1,474 |
$61K |
| D1206 |
Topical application of fluoride varnish |
2,008 |
1,824 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,551 |
1,417 |
$40K |
| D1351 |
Sealant - per tooth |
1,020 |
237 |
$31K |
| D1310 |
|
681 |
622 |
$29K |
| D1330 |
|
679 |
620 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
183 |
98 |
$15K |
| D0603 |
|
1,119 |
1,030 |
$14K |
| D0350 |
|
379 |
361 |
$13K |
| D1110 |
Prophylaxis - adult |
232 |
215 |
$13K |
| D1354 |
|
586 |
99 |
$12K |
| D0272 |
Bitewings - two radiographic images |
511 |
465 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
53 |
$12K |
| D0425 |
|
209 |
194 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
253 |
230 |
$9K |
| D9248 |
|
35 |
31 |
$6K |
| D1320 |
|
138 |
132 |
$5K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$4K |
| D9630 |
|
229 |
215 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
94 |
85 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
81 |
$3K |
| D1353 |
|
88 |
40 |
$3K |
| D0274 |
Bitewings - four radiographic images |
78 |
74 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
39 |
$2K |
| D0240 |
|
66 |
31 |
$1K |
| D9920 |
|
12 |
12 |
$675.29 |