| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,536 |
1,536 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,367 |
2,367 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,778 |
1,778 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,889 |
2,889 |
$46K |
| D1120 |
Prophylaxis - child |
1,061 |
1,061 |
$36K |
| D0240 |
|
1,333 |
1,332 |
$25K |
| D1351 |
Sealant - per tooth |
456 |
149 |
$13K |
| D0330 |
Panoramic radiographic image |
228 |
228 |
$11K |
| D0272 |
Bitewings - two radiographic images |
369 |
369 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
145 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
39 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
231 |
217 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
36 |
31 |
$1K |