| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
845 |
798 |
$26K |
| D1351 |
Sealant - per tooth |
1,013 |
188 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
891 |
820 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
267 |
175 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,442 |
423 |
$16K |
| D1206 |
Topical application of fluoride varnish |
841 |
831 |
$11K |
| D1110 |
Prophylaxis - adult |
226 |
193 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
85 |
$8K |
| D0272 |
Bitewings - two radiographic images |
441 |
404 |
$8K |
| D0274 |
Bitewings - four radiographic images |
300 |
259 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
561 |
544 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
238 |
224 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
135 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$4K |
| D0330 |
Panoramic radiographic image |
131 |
128 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
237 |
151 |
$1K |
| D0603 |
|
1,333 |
1,229 |
$0.00 |
| D0602 |
|
24 |
24 |
$0.00 |