| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,817 |
4,727 |
$195K |
| D0120 |
Periodic oral evaluation - established patient |
6,500 |
6,366 |
$174K |
| D1206 |
Topical application of fluoride varnish |
6,992 |
6,845 |
$162K |
| D1110 |
Prophylaxis - adult |
2,093 |
2,036 |
$108K |
| D0272 |
Bitewings - two radiographic images |
2,756 |
2,689 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
306 |
185 |
$35K |
| D1351 |
Sealant - per tooth |
911 |
201 |
$30K |
| D1330 |
|
3,653 |
3,570 |
$22K |
| D0330 |
Panoramic radiographic image |
292 |
282 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
226 |
197 |
$4K |
| D9248 |
|
13 |
12 |
$2K |
| D3120 |
|
53 |
27 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
121 |
$1K |
| D9310 |
|
13 |
13 |
$624.00 |
| D0274 |
Bitewings - four radiographic images |
39 |
37 |
$602.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$251.00 |