| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,152 |
2,152 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,345 |
2,345 |
$55K |
| D1206 |
Topical application of fluoride varnish |
1,011 |
1,011 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,467 |
1,467 |
$18K |
| D1351 |
Sealant - per tooth |
414 |
164 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,010 |
1,010 |
$14K |
| D1110 |
Prophylaxis - adult |
223 |
223 |
$9K |
| D1354 |
|
250 |
84 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
206 |
130 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
73 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
297 |
291 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
157 |
157 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
24 |
$1K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$963.30 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
121 |
112 |
$800.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
25 |
$205.20 |