| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,782 |
2,744 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
3,228 |
3,193 |
$75K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,338 |
3,319 |
$71K |
| D1351 |
Sealant - per tooth |
2,398 |
393 |
$68K |
| D1110 |
Prophylaxis - adult |
1,174 |
1,171 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
884 |
840 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
463 |
329 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,111 |
1,093 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
327 |
208 |
$17K |
| D0603 |
|
1,328 |
1,326 |
$13K |
| D0330 |
Panoramic radiographic image |
224 |
224 |
$10K |
| D1330 |
|
1,512 |
1,507 |
$7K |
| D0274 |
Bitewings - four radiographic images |
203 |
201 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
481 |
470 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
149 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
263 |
261 |
$3K |
| D1354 |
|
89 |
73 |
$3K |
| D0602 |
|
103 |
103 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$333.06 |
| D9215 |
|
14 |
14 |
$176.30 |