| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,952 |
4,701 |
$210K |
| D1206 |
Topical application of fluoride varnish |
4,793 |
4,551 |
$165K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,387 |
2,256 |
$71K |
| D1351 |
Sealant - per tooth |
3,556 |
537 |
$67K |
| D0274 |
Bitewings - four radiographic images |
2,814 |
2,659 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
3,818 |
3,572 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
799 |
461 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,752 |
4,253 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,285 |
1,213 |
$31K |
| D0330 |
Panoramic radiographic image |
639 |
594 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
577 |
508 |
$10K |
| D0350 |
|
1,595 |
1,250 |
$4K |
| D0999 |
Unspecified diagnostic procedure, by report |
127 |
126 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
65 |
$4K |
| D0272 |
Bitewings - two radiographic images |
162 |
154 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
118 |
118 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
99 |
99 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D0603 |
|
371 |
356 |
$999.00 |
| D1353 |
|
48 |
12 |
$459.20 |
| D7111 |
|
13 |
13 |
$403.00 |
| D0602 |
|
153 |
149 |
$367.00 |
| D1999 |
|
14 |
14 |
$210.00 |
| D0601 |
|
65 |
64 |
$123.00 |